Osteoporosis in men

Insufficiency fracture of the supra-acetabulum that required differentiation from a pathological fracture secondary to a malignant bone tumor: a case report

Background

The supra-acetabulum is a common site for malignant bone tumors, which can be difficult to differentiate from insufficiency fractures. We report a rare case of a stress fracture of the supra-acetabulum that required differentiation from a malignant bone tumor.

Case presentation

A 74-year-old Japanese man presented to the hospital because of right hip joint pain. X-rays showed no obvious abnormalities. Magnetic resonance imaging showed an abnormality in the right supra-acetabulum, and he was referred to our department. A linear, low-signal region and its surrounding equal signal region were observed at the same site in the T1-weighted image, and a linear low-signal region and high signal region were observed in the surrounding area in the T2-weighted image. On the contrast-enhanced magnetic resonance imaging, the lesion was still unclear and the whole area was gradually enhanced. A computed tomography-guided needle biopsy was performed, but no tumor cells were observed, therefore the lesion was presumed to be a fracture healing. The bone density was 66% for the lumbar spine (young adult mean, L2–4), and blood biochemistry showed an increase in alkaline phosphatase and total type I procollagen N-terminal propeptide.

Conclusion

This case was diagnosed as an insufficiency fracture of the supra-acetabulum in a male patient with primary osteoporosis by biopsy specimen. Initially, a pathological fracture associated with a malignant lesion was considered. On magnetic resonance imaging, the boundary around the fracture line was unclear and a signal change that was gradually enhanced by gadolinium was observed. This is likely to be bone marrow edema associated with the stress fracture, and we believe this to be a useful finding that may help in differentiating a stress fracture from a pathological fracture secondary to a malignant lesion.

Hypogonadism, Type-2 Diabetes Mellitus, and Bone Health: A Narrative Review

One of the complications from chronic hyperglycemia and insulin resistance due to type 2 diabetes mellitus (T2DM) on the hypothalamic-pituitary-gonadal axis in men is the high prevalence of hypogonadotropic hypogonadism (HH). Both T2DM and hypogonadism are associated with impaired bone health and increased fracture risk but whether the combination results in even worse bone disease than either one alone is not well-studied. It is possible that having both conditions predisposes men to an even greater risk for fracture than either one alone. Given the common occurrence of HH or hypogonadism in general in T2DM, a significant number of men could be at risk. To date, there is very little information on the bone health men with both hypogonadism and T2DM. Insulin resistance, which is the primary defect in T2DM, is associated with low testosterone (T) levels in men and may play a role in the bidirectional relationship between these two conditions, which together may portend a worse outcome for bone. The present manuscript aims to review the available evidences on the effect of the combination of hypogonadism and T2DM on bone health and metabolic profile, highlights the possible metabolic role of the skeleton, and examines the pathways involved in the interplay between bone, insulin resistance, and gonadal steroids.

Aberrant tryptophan transport in cultured fibroblast from patients with Male Idiopathic Osteoporosis: An in vitro study

It has been demonstrated, that long-term chronic tryptophan deficiency, results in decreased serotonin synthesis, which may lead to low bone mass and low bone formation. Findings from studies in male patients with idiopathic osteoporosis suggested a decreased transport of tryptophan in erythrocytes of osteoporotic patients, indicating that serotonin system defects may be involved in the etiology of low bone mass. Tryptophan is the precursor of serotonin, and a disturbed transport of tryptophan is implicated in altered serotonin synthesis. However, no study has investigated the tryptophan transport kinetics in MIO patients. The aim of this study is to investigate the kinetic parameters of tryptophan transport in fibroblasts derived from MIO patients compared to age and sex matched controls. Fibroblast cells were cultured from skin biopsies obtained from 14 patients diagnosed with Male Idiopathic Osteoporosis and from 13 healthy age-sex matched controls, without a diagnosis of osteoporosis. Transport of the amino acid tryptophan across the cell membrane was measured by the cluster tray method. The kinetic parameters, maximal transport capacity (V_max) and affinity constant (K_m) were determined by using the Lineweaver-Burke plot equation. The results of this study have shown a significantly lower mean value for V_max (p = 0.0138) and lower K_m mean value (p = 0.0009) of tryptophan transport in fibroblasts of MIO patients compared to the control group. A lower V_max implied a decreased tryptophan transport availability in MIO patients. In conclusion, reduced cellular tryptophan availability in MIO patients might result in reduced brain serotonin synthesis and its endogenous levels in peripheral tissues, and this may contribute to low bone mass/formation. The findings of the present study could contribute to the etiology of idiopathic osteoporosis and for the development of novel approaches for diagnosis, treatment and management strategies of MIO.

Gender Differences and Socioeconomic Factors Related to Osteoporosis: A Cross-Sectional Analysis of Nationally Representative Data

BACKGROUND

Osteoporosis has been considered a disease that primarily affects women, but recently male osteoporosis is also attracting attention. This study aims to comparatively analyze socioeconomic and other factors that are related to the prevalence of osteoporosis in both men and women.

MATERIALS AND METHODS

This study used data from the Korean Community Health Survey conducted in 2013. To determine factors related to osteoporosis prevalence, researchers applied a binary logistic regression model, first for all research participants, then separately for male and female participants.

RESULTS

Women were more likely than men to have osteoporosis (odds ratio 12.33, 95% confidence interval 11.55-13.17). Factors related to osteoporosis prevalence included age, education level, region, economic activity, alcohol consumption, salt intake, depression, and body mass index in both genders. Low education and income levels were more highly associated with osteoporosis prevalence in women than in men.

CONCLUSIONS

Most of the factors were not gender specific, but some socioeconomic determinants varied by gender. Future studies that will focus on the effects of socioeconomic factors on osteoporosis, as well as gender-related differences in prevention and control of osteoporosis, are needed.

Denosumab is really effective in the treatment of osteoporosis secondary to hypogonadism in prostate carcinoma patients? A prospective randomized multicenter international study

INTRODUCTION

Osteoporosis is a complication of androgen deprivation therapy (ADT) in men with prostate carcinoma. The best defense against osteoporosis in prostate cancer is to identify patients with a high risk for fracture during the first clinical visit, select an effective anti-osteoporosis agent, and advise the patient to change his lifestyle and diet to prevent further bone loss. New agents include denosumab, a human monoclonal antibody that inhibits the RANK ligand (RANKL). RANKL promotes the formation, activity, and survival of osteoclasts and, thus, supports the breakdown of bone.

PURPOSE

This is a multicenter, randomized, double-blind prospective study on use of denosumab versus alendronate in the therapy of secondary osteoporosis related to ADT in prostate cancer patients in three European countries (Italy, France, Switzerland).

PATIENTS AND METHODS

In this 24-month observation study we enrolled 234 patients with diagnosis of osteoporosis underwent ADT for prostate cancer. All patients aged ≥55 years and had a dual-energy X-ray absorptiometry (DEXA) T-score <-1.0 (hip or spine, measured within last 2 years) and ≥ 1 fragility fracture. Patients were randomly assigned 1:1 to receive denosumab 60 mg subcutaneously every 6 months or alendronate (70 mg weekly) for 2 years. All patient received supplemental vitamin D (600 IU per day) and supplemental calcium to maintain a calcium intake of 1200 mg per day. Effectiveness of therapy in both groups (denosumab group and alendronate group) was assessed by changes in bone turnover markers (BTMs), Bone Mineral Density (BMD), fracture incidence, Visual Analogue Scale (VAS) score for back pain, and Short Form-8 (SF-8TM) health survey score for health-related quality of life (HRQoL). Percent changes from baseline in BTMs and BMD were assessed using the paired t test; a P-value 0.05). Mean changes in BMD at final follow-up differed significantly between two groups. BMD changes at the lumbar spine at 24 months were 5.6% with denosumab vs -1.1% with alendronate (P<0.001). New vertebral fractures developed in fewer patients in the denosumab group than in the alendronate group during the 24-month period, although this difference was not significant (P=0.10). Back pain significantly (P<0.001) improved from baseline at all time points during the study in both study groups. SF-8 health survey scores significantly improved following treatment with both drugs. Incidence of adverse drug reactions were similar in both groups.

CONCLUSION

In our study denosumab and alendronate showed similar clinical efficacy in the therapy of ADT-related osteoporosis in men with prostate carcinoma; both drugs provided significant improvements in back pain and general health conditions. Denosumab showed significant increase of BTMs and BMD than alendronate with lower rate of new vertebral fractures.

Fluoride-induced modulation of ionic transport in asymmetric nanopores functionalized with "caged" fluorescein moieties

We demonstrate experimentally and theoretically a nanofluidic fluoride sensing device based on a single conical pore functionalized with "caged" fluorescein moieties. The nanopore functionalization is based on an amine-terminated fluorescein whose phenolic hydroxyl groups are protected with tert-butyldiphenylsilyl (TBDPS) moieties. The protected fluorescein (Fcn-TBDPS-NH2) molecules are then immobilized on the nanopore surface via carbodiimide coupling chemistry. Exposure to fluoride ions removes the uncharged TBDPS moieties due to the fluoride-promoted cleavage of the silicon-oxygen bond, leading to the generation of negatively charged groups on the fluorescein moieties immobilized onto the pore surface. The asymmetrical distribution of these groups along the conical nanopore leads to the electrical rectification observed in the current-voltage (I-V) curve. On the contrary, other halides and anions are not able to induce any significant ionic rectification in the asymmetric pore. In each case, the success of the chemical functionalization and deprotection reactions is monitored through the changes observed in the I-V curves before and after the specified reaction step. The theoretical results based on the Nernst-Planck and Poisson equations further demonstrate the validity of an experimental approach to fluoride-induced modulation of nanopore current rectification behaviour.

Simultaneous Quantitation of Estradiol and Estrone in Serum Using Liquid Chromatography Mass Spectrometry

Accurate measurement of the endogenous estrogens, estrone (E1) and estradiol (E2), is important in the clinical diagnosis and monitoring of multiple disorders. Typically, given the efficacy and low cost, radioimmunoassays (RIA) and enzyme-linked immunoassays (EIA) are used to quantify these hormones in biological samples. Unfortunately, at low levels these assays lack the necessary sensitivity and specificity for diagnosis of certain disorders in adult and pediatric endocrinology and oncology. In response to this need, we developed a fast and sensitive high performance liquid chromatography negative electrospray ionization tandem mass spectrometry (LC-MS/MS) method to measure serum estrone (E1) and estradiol (E2) without chemical derivatization. Samples are spiked with a stable isotopic carbon thirteen ((13)C) labeled internal standard and the estrogens are isolated by liquid-liquid extraction (LLE) with hexane:Methyl-tert-butyl ether (MTBE) (9:1). Following centrifugation and dry down samples are reconstituted with deionized water, and separated on a C18 reverse phase column. The analytes are quantified using a six point calibration curve with a linearity of 2.6-625 pg/ml and with a variability of less than 8 % across analytical range.

Vertebral microarchitecture and fragility fracture in men: a TBS study

INTRODUCTION

Although osteoporosis is considered a disease of women, 25% of the individuals with osteoporosis are men. BMD measurement by DXA is the gold standard used to diagnose osteoporosis and assess fracture risk. Nevertheless, BMD does not take into account alterations of microarchitecture. TBS is an index of bone microarchitecture extracted from the spine DXA. Previous studies have reported the ability of the spine TBS to predict osteoporotic fractures in women. This is the first case-controlled study in men to evaluate the potential diagnostic value of TBS as a complement to bone mineral density (BMD), by comparing men with and without fractures.

METHODS

To be eligible for this study, subjects had to be non-Hispanic US white men aged 40 and older. Furthermore, subjects were excluded if they have or have had previously any treatment or illness that may influence bone metabolism. Fractured subjects were included if the presence of at least one fracture was confirmed. Cases were matched for age (±3 years) and BMD (±0.04 g/cm(2)) with three controls. BMD and TBS were first retrospectively evaluated at AP spine (L1-L4) with a Prodigy densitometer (GE-Lunar, Madison, USA) and TBS iNsight® (Med-Imaps, France) in Lausanne University Hospital blinded from clinical outcome. Inter-group comparisons were undertaken using Student's t-tests or Wilcoxon signed rank tests. Odds ratios were calculated per one standard deviation decrease as well as areas under the receiver operating curve (AUC).

RESULTS

After applying inclusion/exclusion criteria, a group of 180 male subjects was obtained. This group consists of 45 fractured subjects (age=63.3±12.6 years, BMI=27.1±4.2 kg/m(2)) and 135 control subjects (age=62.9±11.9 years, BMI=26.7±3.9 kg/m(2)) matched for age (p=0.86) and BMD (p=0.20). A weak correlation was obtained between TBS and BMD and between TBS and BMI (r=0.27 and r=-0.28, respectively, p<0.01). Subjects with fracture have a significant lower TBS compared to control subjects (p=0.013), whereas no differences were obtained for BMI, height and weight (p>0.10). TBS OR per standard deviation is 1.55 [1.09-2.20] for all fracture type. When considering vertebral fracture only TBS OR reached 2.07 [1.14-3.74].

CONCLUSION

This study showed the potential use of TBS in men. TBS revealed a significant difference between fractured and age- and spine BMD-matched nonfractured subjects. These results are consistent with those previously reported on for men of other nationalities.

Decreased bone mineral density and periodontal management

The definition of osteoporosis has evolved beyond low bone mineral density to include impaired bone morphology and matrix properties. As such, the subsequent bone density insufficiencies extend beyond the skeletal risks of fracture and have implications for oral health management patients. As our population ages there is a worldwide increase in the risk of decreased bone mineral density and its subsequent morbidity. This makes age an independent risk factor for fracture and decreased bone mineral density. Multiple examinations and diagnostic tests are currently used in combination to develop an algorithm to assess osteoporotic risk. Oral health care professionals should follow these principles and caution should be used in applying a single independent assessment to determine a patient's osteoporotic or bone metabolism risk. Therapeutic approaches for osteoporosis are often divided into nonpharmacological interventions and pharmacological therapies. The periodontist and other oral health care professionals should have a full understanding of the therapeutic options, benefits and implementation of preventive therapies. Bone turnover is a coupled event of bone formation and bone resorption and it is the imbalance of this homeostasis that results in osteoporosis. Based on this uncoupling of bone resorption and formation, osteoporosis or decreased bone mineral density and osteopenia, may be a risk factor for alveolar bone loss in periodontitis. The role of prevention and maintenance with a history of periodontitis and oesteopenia extends beyond biofilm control and should include management of bone mineral density. The chronic periodontal infection in a patient with osteopenia may place the patient at greatly increased risk for alveolar bone loss, gingival recession and root caries. A key component in the management is the oral health professional's knowledge of the interrelationship between skeletal health and periodontal health.

Bone mineral density in prostate cancer: a comparative study of patients with prostate cancer and healthy controls using propensity score matching

OBJECTIVE

To determine whether the prevalence of prostate cancer is associated with a decrease in bone mineral density (BMD) compared to a healthy control group and to identify the factors associated with osteoporosis in patients diagnosed with prostate cancer before the initiation of any kind of treatment.

MATERIALS AND METHODS

A retrospective study was conducted in 582 patients with prostate cancer and 2536 healthy men. Confounding variables affecting BMD, including age, serum testosterone, body mass index (BMI), diabetes mellitus, hypertension, and smoking were matched in the 2 study groups using propensity score analysis.

RESULTS

The propensity score model included 6 variables, and matching by propensity score yielded 502 patients in the prostate cancer group matched to 502 men in the healthy control group. On the basis of the lowest T-score available, a high prevalence of osteoporosis was found in the prostate cancer group (P = .0001). Prostate cancer was the factor correlating significantly with osteoporosis before propensity score matching (odds ratio [OR] 2.96, P <.001) and after propensity score matching (OR 3.22, P <.001). By multivariate analysis, conducted to assess the significance of each variable affecting the development of osteoporosis in patients with prostate cancer, bone metastasis was found to be an independent predictor of osteoporosis (OR 3.45, P = .002), along with BMI (continuous, OR 0.75, P <.001).

CONCLUSION

After controlling for variables affecting BMD, prostate cancer was a risk factor for osteoporosis. Measurement of BMD is a logical first step in the clinical strategy to avoid or minimize potential bone-related complications in men with prostate cancer, especially if they have bone metastasis and a slender stature.

Neonatal rat osteoblasts bioconvert testosterone to non-phenolic metabolites with estrogen-like effects on bone cell proliferation and differentiation

Testosterone (T) restores bone mass loss in postmenopausal women and osteoporotic men mainly through its bioconversion to estradiol (E2). In target tissues, T is also biotransformed to the A-ring-reduced metabolites 3α,5α-androstanediol (3α,5α-diol) and 3β,5α-androstanediol (3β,5α-diol), which are potent estrogen receptor (ER) agonists; however, their biological role in bone has not been completely elucidated. To assess if osteoblasts bioconvert T to 3α,5α-diol and to 3β,5α-diol, we studied in cultured neonatal rat osteoblasts the metabolism of [14C]-labeled T. In addition, the intrinsic estrogenic potency of diols on cell proliferation and differentiation in neonatal calvarial rat osteoblasts was also investigated. Osteoblast function was assessed by determining cell DNA, cell-associated osteocalcin, and calcium content, as well as alkaline phosphatase activity and Alp1 gene expression. The results demonstrated that diols were the major bioconversion products of T, with dihydrotestosterone being an obligatory intermediary, thus demonstrating in the rat osteoblasts the activities of 5α-steroid reductase and 3α- and 3β-hydroxysteroid dehydrogenases. The most important finding was that 3β,5α- and 3α,5α-diols induced osteoblast proliferation and differentiation, mimicking the effect of E2. The observation that osteoblast differentiation induced by diols was abolished by the presence of the antiestrogen ICI 182,780, but not by the antiandrogen 2-hydroxyflutamide, suggests that diols effects are mediated through an ER mechanism. The osteoblast capability to bioconvert T into diols with intrinsic estrogen-like potency offers new insights to understand the mechanism of action of T on bone cells and provides new avenues for hormone replacement therapy to maintain bone mass density.

Comparison of Tamoxifen and Testosterone Propionate in Male Rats: Differential Prevention of Orchidectomy Effects on Sex Organs, Bone Mass, Growth, and the Growth Hormone-IGF-I Axis

Testis dysfunction can weaken bone and reduce muscle mass as well as impair sexual function. Testosterone (T) therapy has useful effects on sex organs, bone, and muscle in T-deficient males, but prostate concerns can preclude T use in some men. Although estrogens or other drugs can protect bone in men, gynecomastia makes estrogens unappealing, and other drugs may also be undesirable in some cases. Selective estrogen receptor modulators (SERMs) inhibit estrogen-evoked sex organ growth but mimic estrogen effects on bone and cholesterol and are advantageous for some women. SERMs may also be useful in men who must avoid androgens. As a preclinical test of this idea, tamoxifen (a SERM) and testosterone propionate (TP, a classic androgen) were compared for their efficacy in preventing varied effects of orchidectomy (ORX) in adult male rats. ORX led to ventral prostate and seminal vesicle atrophy and decreases in somatic growth, proximal tibia bone mineral density (BMD), and serum growth hormone (GH) and insulin-like growth factor I (IGF-I). ORX also increased anterior pituitary glandular kallikrein, serum cholesterol, and body temperature. Pituitary prolactin (PRL) content was unaltered. ORX effects on sex organs, somatic growth, IGF-I, cholesterol, body temperature, and pituitary kallikrein were prevented by TP at 1 mg/kg (3 doses per week), but BMD and GH were unresponsive. ORX effects on BMD and GH were prevented by TP at 10 mg/kg, but this dose evoked supraphysiologic increases in sex organs and PRL, failed to restore somatic growth, and further reduced IGF-I. Tamoxifen (1 mg/kg daily) prevented ORX effects on BMD, GH, and cholesterol without altering basal or TP-induced sex organ growth and further reduced IGF-I and somatic growth. Tamoxifen did not alter basal PRL but blocked increases caused by TP at 10 mg/kg. In summary, tamoxifen prevented ORX effects on bone and cholesterol in male rats without affecting sex organs or PRL and might be useful for men who must avoid androgens. Unexpectedly, a TP dose that replicated testis effects on sex organs and other targets had no effect on BMD or GH, and a larger TP dose that restored BMD and GH was worse at replicating normal male physiology. In addition, correlation/regression results suggested that the GH-IGF-I axis contributes to changes in BMD.

Male osteoporosis: A review

Osteoporosis in men is a heterogeneous disease that has received little attention. However, one third of worldwide hip fractures occur in the male population. This problem is more prevalent in people over 70 years of age. The etiology can be idiopathic or secondary to hypogonadism, vitamin D deficiency and inadequate calcium intake, hormonal treatments for prostate cancer, use of toxic and every disease or drug use that alters bone metabolism.Risk factors such as a previous history of fragility fracture should be assessed for the diagnosis. However, risk factors in men are very heterogeneous. There are significant differences in the pharmacological treatment of osteoporosis between men and women fundamentally due to the level of evidence in published trials supporting each treatment. New treatments will offer new therapeutic prospects. The goal of this work is a revision of the present status knowledge about male osteoporosis.

The effects of tualang honey on bone metabolism of postmenopausal women

Osteoporosis which is characterized by low bone mass and microarchitectural deterioration with a consequent increase in bone fragility can be associated with various stimuli such as oxidative stress and inflammation. Postmenopausal women are more prone to osteoporosis due to reduction in estrogen which may further lead to elevation of oxidative stress and lipid accumulation which will promote osteoblasts apoptosis. Proinflammatory cytokines are elevated following estrogen deficiency. These cytokines are important determinants of osteoclasts differentiation and its bone resorption activity. The main treatment for postmenopausal osteoporosis is estrogen replacement therapy (ERT). Despite its effectiveness, ERT, however, can cause many adverse effects. Therefore, alternative treatment that is rich in antioxidant and can exert an anti-inflammatory effect can be given to replace the conventional ERT. Tualang honey is one of the best options available as it contains antioxidant as well as exerting anti-inflammatory effect which can act as a free radical scavenger, reducing the oxidative stress level as well as inhibiting proinflammatory cytokine. This will result in survival of osteoblasts, reduced osteoclastogenic activity, and consequently, reduce bone loss. Hence, Tualang honey can be used as an alternative treatment of postmenopausal osteoporosis with minimal side effects.

Interaction between exercise, dietary restriction and age-related bone loss in a rodent model of male senile osteoporosis

BACKGROUND

The pathophysiology of age-related bone loss and whether age-related bone loss can be prevented by exercise are still a matter of debate.

OBJECTIVE

It was the aim of this study to investigate the long-term effects of exercise and mild food restriction on bone mineral density (BMD) and bone geometry in the appendicular skeleton of aging male rats.

METHODS

Male Sprague-Dawley rats were studied from 5 to 23 months of age. The rats were divided into 4 groups: baseline, free access to food and running wheels (RW), fed to pair weight with the RW group (PW) and sedentary control animals with free access to food (SED). All rats were housed individually. Volumetric BMD and geometry of femurs and tibiae were assessed by peripheral quantitative computed tomography (pQCT). In addition, the tibial shafts were analyzed by cortical bone histomorphometry.

RESULTS

At the end of the experiment, RW and PW rats had similar body weight. The body weight of SED rats was 31% greater than that of RW rats. pQCT analysis of femurs and tibiae as well as histomorphometric analysis of the tibial shafts showed that dietary restriction resulted in an enlargement of the marrow cavity and cortical thinning at the femoral and tibial shafts relative to the RW and SED groups. Voluntary running exercise provided no additional protection against age-related bone loss when compared with the 31% heavier SED control rats. Neither exercise nor increased body weight in SED animals could completely prevent age-related bone loss between 19 and 23 months of age.

CONCLUSION

We conclude that dietary restriction had clear negative effects on BMD and bone geometry and that running wheel exercise provided partial protection but could not prevent age-related bone loss.

Comparison of antegonial index, mental index, panoramic mandibular index and mandibular cortical index values in the panoramic radiographs of normal males and male patients with osteoporosis

OBJECTIVE

The aim of the study was to compare the values of the antegonial index (AI), mental index (MI), panoramic mandibular index (PMI) and mandibular cortical index (MCI) in the panoramic radiographs of normal males and male patients with osteoporosis.

METHODS

In panoramic radiographs obtained from 40 male individuals (20 normal and 20 with osteoporosis), the mean was calculated for MI, AI, PMI and MCI index values measured in the right and left mandibles. The MI, AI and PMI index values were evaluated using the paired t-test, and MCI values were analysed using the chi(2) test.

RESULTS

MI (P < 0.001), AI (P < 0.01) and PMI (P < 0.05) values were significantly smaller in the group with osteoporosis; however, MCI (P > 0.05) was not significantly different.

CONCLUSION

MI, PMI and AI values, as radiomorphometric indices, were found to be smaller among male patients with osteoporosis, compared with normal patients in this study. It is suggested that these indices, used as an ancillary method in the diagnosis of osteoporosis in women, could also be useful for male patients. Further studies, of larger groups are needed on this subject, including of the MCI, which in this study showed no significant difference.

Reduced proliferation and osteocalcin expression in osteoblasts of male idiopathic osteoporosis

Osteoporosis is characterized by low bone mineral density (BMD), resulting in increasing susceptibility to bone fractures. In men, it has been related to some diseases and toxic habits, but in some instances the cause of the primary--or idiopathic--osteoporosis is not apparent. In a previous study, our group compared histomorphometric measurements in cortical and cancellous bones from male idiopathic osteoporosis (MIO) patients to those of control subjects and found reduced bone formation without major differences in bone resorption. To confirm these results, this study analyzed the etiology of this pathology, examining the osteoblast behavior in vitro. We compared two parameters of osteoblast activity in MIO patients and controls: osteoblastic proliferation and gene expression of COL1A1 and osteocalcin, in basal conditions and with vitamin D(3) added. All these experiments were performed from a first-passage osteoblastic culture, obtained from osteoblasts that had migrated from the transiliac explants to the plate. The results suggested that the MIO osteoblast has a slower proliferation rate and decreased expression of genes related to matrix formation, probably due to a lesser or slower response to some stimulus. We concluded that, contrary to female osteoporosis, in which loss of BMD is predominantly due to increased resorption, low BMD in MIO seems to be due to an osteoblastic defect.

High sensitivity measurement of estrone and estradiol in serum and plasma using LC-MS/MS

Measurement of low concentrations of estrogens, encountered in pre-pubertal children, men, and postmenopausal women, is important for numerous clinical applications. We describe a method for high sensitivity analysis of estrogens that uses two-dimensional chromatographic separation and tandem mass spectrometry detection. Aliquots of serum or plasma samples are combined with stable isotope-labeled internal standard and estrogens are extracted with methyl t-butyl ether. The solvent is evaporated, estrogens derivatized to form dansyl derivatives, and the samples are analyzed. Quantitation is performed using triple quadrupole mass spectrometer equipped with electrospray ion source using positive ion mode ionization and multiple reaction monitoring acquisition.

Osteoporosis in Long-Term Care Residents with Multiple Sclerosis

OBJECTIVE

To assess the fracture risk of long-term care residents with multiple sclerosis (MS) using ultrasound heel-scan technology and identification of risk factors and areas where intervention by a pharmacist might affect patient outcomes.

DESIGN

Bilateral-heel scans were performed on all patients who consented to take part in the study. A retrospective review of each subject's medical records was performed to identify known risk factors for osteoporosis.

SETTING

A long-term care facility in Omaha, Nebraska.

PARTICIPANTS

All patients with a primary diagnosis of MS residing at the facility were eligible for participation. Of 11 patients identified, 10 consented to participate.

MAIN OUTCOME MEASURES

T-scores of the right and left heel as determined by ultrasound-heel scan were used to determine if study participants met criteria for osteopenia or osteoporosis as set forth by the World Health Organization.

CONCLUSION

Patients in our population who have MS are at high risk for fracture. There are several areas in which pharmacists can intervene to prevent fracture and improve patient outcomes, including administration of heel scans for persons believed to be at risk, recommendation of over-the-counter supplements, and education of both patients and health care practitioners.

Osteoporosis: "A risk factor for periodontitis"

Aging is one of the major health challenges today. Most of the diseases related to aging, lead to significantly increased morbidity and mortality and higher public expenditure of funds. The interconnection between socio-economic conditions and social vulnerability is reflected in precarious states of health with prominence of high rates of osteoporosis and periodontal disease.Both these diseases have been highlighted in public health because of the impact caused by bone fracture and tooth loss. Thus, the elderly could help live a healthier and more meaningful life with the prevention of these diseases.

Type 2 diabetic mice demonstrate slender long bones with increased fragility secondary to increased osteoclastogenesis

Type 2 diabetics often demonstrate normal or increased bone mineral density, yet are at increased risk for bone fracture. Furthermore, the anti-diabetic oral thiazolidinediones (PPARgamma agonists) have recently been shown to increase bone fractures. To investigate the etiology of possible structural and/or material quality defects, we have utilized a well-described mouse model of Type 2 diabetes (MKR). MKR mice exhibit muscle hypoplasia from birth with reduced mass by the pre-diabetic age of 3 weeks. A compensatory hyperplasia ensues during early (5 weeks) development; by 6-8 weeks muscle is normal in structure and function. Adult whole-bone mechanical properties were determined by 4-point bending to test susceptibility to fracture. Micro-computed tomography and cortical bone histomorphometry were utilized to assess static and dynamic indices of structure, bone formation and resorption. Osteoclastogenesis assays were performed from bone marrow-derived non-adherent cells. The 8-week and 16-week, but not 3-week, male MKR had slender (i.e., narrow relative to length) femurs that were 20% weaker (p<0.05) relative to WT control femurs. Tissue-level mineral density was not affected. Impaired periosteal expansion during early diabetes resulted from 250% more, and 40% less of the cortical bone surface undergoing resorption and formation, respectively (p<0.05). Greater resorption persisted in adult MKR on both periosteal and endosteal surfaces. Differences were not limited to cortical bone as the distal femur metaphysis of 16 week MKR contained less trabecular bone and trabecular separation was greater than in WT by 60% (p<0.05). At all ages, MKR marrow-derived cultures demonstrated the ability for enhanced osteoclast differentiation in response to M-CSF and RANK-L. Taken together, the MKR mouse model suggests that skeletal fragility in Type 2 diabetes may arise from reduced transverse bone accrual and increased osteoclastogenesis during growth that is accelerated by the diabetic/hyperinsulinemic milieu. Further, these results emphasize the importance of evaluating diabetic bone based on morphology in addition to bone mass.

Bone mass is preserved and cancellous architecture altered due to cyclic loading of the mouse tibia after orchidectomy

INTRODUCTION

The study of adaptation to mechanical loading under osteopenic conditions is relevant to the development of osteoporotic fracture prevention strategies. We previously showed that loading increased cancellous bone volume fraction and trabecular thickness in normal male mice. In this study, we tested the hypothesis that cyclic mechanical loading of the mouse tibia inhibits orchidectomy (ORX)-associated cancellous bone loss.

MATERIALS AND METHODS

Ten-week-old male C57BL/6 mice had in vivo cyclic axial compressive loads applied to one tibia every day, 5 d/wk, for 6 wk after ORX or sham operation. Adaptation of proximal cancellous and diaphyseal cortical bone was characterized by muCT and dynamic histomorphometry. Comparisons were made between loaded and nonloaded contralateral limbs and between the limbs of ORX (n = 10), sham (n = 11), and basal (n = 12) groups and tested by two-factor ANOVA with interaction.

RESULTS

Cyclic loading inhibited bone loss after ORX, maintaining absolute bone mass at age-matched sham levels. Relative to sham, ORX resulted in significant loss of cancellous bone volume fraction (-78%) and trabecular number (-35%), increased trabecular separation (67%), no change in trabecular thickness, and smaller loss of diaphyseal cortical properties, consistent with other studies. Proximal cancellous bone volume fraction was greater with loading (ORX: 290%, sham: 68%) than in contralateral nonloaded tibias. Furthermore, trabeculae thickened with loading (ORX: 108%, sham: 48%). Dynamic cancellous bone histomorphometry indicated that loading was associated with greater mineral apposition rates (ORX: 32%, sham: 12%) and smaller percent mineralizing surfaces (ORX: -47%, sham: -39%) in the final week. Loading resulted in greater BMC (ORX: 21%, sham: 15%) and maximum moment of inertia (ORX: 39%, sham: 24%) at the cortical midshaft.

CONCLUSIONS

This study shows that cancellous bone mass loss can be prevented by mechanical loading after hormonal compromise and supports further exploration of nonpharmacologic measures to prevent rapid-onset osteopenia and associated fractures.

The relationship between periodontal status and alkaline phosphatase levels in gingival crevicular fluid in men with hypergonadotropic hypogonadism

PURPOSE

The aim of this preliminary study was to determine the possible relationship between alkaline phosphatase (ALP) levels in the gingival crevicular fluid (GCF) and periodontal disease in men with hypergonadotropic hypogonadism (HH).

MATERIALS AND METHODS

A total of 41 patients were divided into four groups. 9 with HH and periodontitis (P/HH), 11 with HH and gingivitis (G/HH), 12 with systemically healthy and periodontally healthy (H/C) and 9 with systemically healthy and periodontitis (P/C). The clinical evaluation of patients was based on the following parameters; the plaque index (PI), gingival index (GI), probing depths (PD) and attachment level (AL). The levels of ALP in the GCF were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

No significant difference could be detected in the mean clinical parameter data between the P/HH and P/C groups (p > 0.05). The periodontitis patients in both groups (P/C and P/HH) had higher mean probing depths than the H/C and G/HH patients (p < 0.001). The concentrations and total amounts of ALP in the GCF were significantly higher in both periodontitis groups compared to healthy and gingivitis groups (p < 0.01). The serum ALP levels were significantly higher in the P/HH group when compared to the other groups (p < 0.001).

CONCLUSION

The findings of this study suggested that HH could be implicated as a contributing factor to the progress of periodontal disease.

Alendronate for the treatment of osteoporosis in men

BACKGROUND

Men have higher rates of osteoporosis and suffer fragility fractures more often than previously believed. Fracture-related morbidity and mortality in men is substantially higher than in women.

OBJECTIVE

To investigate alendronate for treating osteoporosis in men.

METHODS

Search limited to 'men' and 'English'; keywords were 'osteoporosis' or 'bone density' or 'fracture' and 'alendronate'.

RESULTS/CONCLUSIONS

Alendronate is an amino-bisphosphonate with proved efficacy for increasing bone mineral density in men with idiopathic or secondary osteoporosis and has demonstrated an ability to prevent vertebral fractures in men with low bone mass. There are trends for alendronate to decrease the risk of non-vertebral fracture, but larger trials are needed to conclusively establish this benefit. Alendronate is a well-tolerated and comparatively safe drug with an attractive once-a-week dosing regimen.

Development and internal validation of the male osteoporosis risk estimation score

PURPOSE

We wanted to develop and validate a clinical prediction rule to identify men at risk for osteoporosis and subsequent hip fracture who might benefit from dual-energy x-ray absorptiometry (DXA).

METHODS

We used risk factor data from the National Health and Nutrition Examination Survey III to develop a best fitting multivariable logistic regression model in men aged 50 years and older randomized to either the development (n = 1,497) or validation (n = 1,498) cohorts. The best fitting model was transformed into a simplified scoring algorithm, the Male Osteoporosis Risk Estimation Score (MORES). We validated the MORES, comparing sensitivity, specificity, and area under the receiver operating characteristics (ROC) curve in the 2 cohorts and assessed clinical utility with an analysis of the number needed-to-screen (NNS) to prevent 1 additional hip fracture.

RESULTS

The MORES included 3 variables-age, weight, and history of chronic obstructive pulmonary disease-and showed excellent predictive validity in the validation cohort. A score of 6 or greater yielded an overall sensitivity of 0.93 (95% CI, 0.85-0.97), a specificity of 0.59 (95% CI, 0.56-0.62), and an area under the ROC curve of 0.832 (95% CI, 0.807-0.858). The overall NNS to prevent 1 additional hip fracture was 279 in a cohort of men representative of the US population.

CONCLUSIONS

Osteoporosis is a major predictor of hip fractures. Experts believe bisphosphonate treatment in men should yield results similar to that in women and reduce hip fracture rates associated with osteoporosis. In men aged 60 years and older, the MORES is a simple approach to identify men at risk for osteoporosis and refer them for confirmatory DXA scans.

Determinants of changes in bone density: a 5-year follow-up study of adult male monozygotic twins

The relative importance of determinants in bone mineral density (BMD) in adult men is partly unclear. Our goals were to investigate the effects of familial aggregation and behavioral factors on the change in BMD during a 5-yr follow-up. Subjects (n=140) were 70 exposure-discordant monozygotic twin pairs (age 35-69 yr). BMD was measured with the same dual-energy X-ray absorptiometry scanner at baseline and at the 5-yr follow-up. A variety of covariates were used including physical examination and interview data. Multivariate linear regression was used. The mean annual decrease in femoral BMD was 0.2%. The mean lumbar BMD was unchanged, although 8-17% of subjects had a decrease of more than 5%. Familial aggregation explained 14% of the changes in femoral BMD and 19% in lumbar BMD. The stability of BMD in the follow-up was high, both for individuals (intraclass correlation coefficient [ICC]=0.90-0.94) and for co-twins in a pair (ICC=0.77-0.84). In femoral BMD, use of alcohol (p=0.006), coffee (p=0.046), and beta-blockers (p=0.043) led to increases, whereas smoking led to a decrease (p<0.01). We concluded that frequent increases in BMD, influenced by beta-blockers, partly explain the minor mean changes during follow-up; however, about every 10th subject had a significant decrease. Overall, familial effects played a dominant role in BMD changes in adult men.

Racial and ethnic differences in bone turnover markers in men

CONTEXT

Whereas racial and ethnic differences in fracture risk and bone mineral density (BMD) in men have been well described, the influence of race and ethnicity on biochemical markers of bone turnover is less clear.

METHODS

To examine the relationship between bone turnover, BMD, and race and ethnicity in men, we measured BMD, serum intact osteocalcin (OC), and serum C-terminal telopeptides of type 1 collagen (CTx) in 1029 men (aged 30-79 yr) enrolled in the Boston Area Community Health/Bone Survey, a population-based random sample of Black, Hispanic, and White. Men with diseases or on medications known to affect bone metabolism were excluded from the analysis. Mean serum levels of OC and CTx were adjusted for age, month and time of blood sample, and 25-hydroxyvitamin D.

RESULTS

Compared with Black men, adjusted mean OC levels were 17.6 and 20.5% higher in Hispanic (P = 0.02) and White men (P < 0.01), respectively. There was no significant difference between White and Hispanic men. Adjusted mean CTx levels were 14.3% higher in White men, compared with Black men (P = 0.04), but no other differences were significant. OC declined by 0.4%/yr from age 30 to 65 yr and increased thereafter by 2.1%/yr. The age trend in CTx appeared to follow a pattern consistent with a quadratic function of age. Model-estimated annual percent changes within age decade were as follows: 30-39 yr, -2.5%; 40-49 yr, -1.4%; 50-59 yr, -0.3%; 60-69 yr, +0.9%; 70-79 yr, +1.7%. There was no variation in the shape of the age trend in OC or CTx by race or ethnic group. Correlations between bone turnover markers and BMD (adjusted for age, height, weight, serum 25-hydroxyvitamin D, and PTH and month and time of blood sample) were generally weak.

CONCLUSIONS

Bone turnover markers are lower in Black men, compared with White and Hispanic men. Age trends in bone turnover markers are not influenced by race or ethnicity. Future studies in this cohort and others are needed to explore further these reported differences in bone metabolism among Black, Hispanic, and White men.

Two-year changes in bone mineral density and T scores in patients treated at a pharmacist-run teriparatide clinic

STUDY OBJECTIVES

To determine changes in bone mineral density (BMD) and T scores of patients after 2 years of teriparatide therapy, and to determine the number of fractures that occurred during therapy.

DESIGN

Prospective, observational study.

SETTING

Pharmacist-run teriparatide clinic in a private-practice endocrinology group.

PATIENTS

Sixty patients with osteoporosis who experienced fractures or adverse events while receiving antiresorptive therapy and were referred by the endocrinologists to the clinic between January 1, 2002, and January 1, 2004.

INTERVENTION

After a 1-hour counseling and training session with a clinical pharmacist, patients self-administered subcutaneous teriparatide 20 microg/day for the next 2 years.

MEASUREMENTS AND MAIN RESULTS

Primary outcome measures were dual x-ray absorptiometry-determined BMDs and T scores for the total hip, spine, and wrist at baseline and at 1 and 2 years. Patients' BMDs for the hip significantly increased by 3.5% at 1 year and by 3.9% at 2 years. In addition, BMD for the spine significantly increased by 7.2% at 1 year and 10.9% at 2 years. In 56 (93%) patients, BMD for the spine increased after 2 years of treatment. For the wrist, BMD decreased by 0.75% at 1 year and by 2.4% at 2 years, but the change was only significant at 2 years (p=0.011). At both 1 and 2 years, T scores for the total hip and spine significantly improved from baseline (p< or =0.019), whereas T scores for the wrist significantly declined after 2 years of therapy (p<0.003). No new fractures were documented in any of the patients.

CONCLUSION

In patients with osteoporosis, the use of teriparatide in a pharmacist-run clinic significantly increased BMD at the total hip and spinal sites and significantly decreased BMD in the wrist.

Androgen deprivation therapy for prostate cancer: new concepts and concerns

PURPOSE OF REVIEW

The aim of this review is to summarize new concepts and concerns regarding treatment-related osteoporosis, diabetes, and cardiovascular disease in men receiving androgen deprivation therapy for prostate cancer.

RECENT FINDINGS

Gonadotropin-releasing hormone agonists increase bone turnover, decrease bone mineral density, and increase fracture risk. Bisphosphonates, selective and estrogen receptor modulators significantly increase bone mineral density during androgen deprivation therapy. Ongoing randomized controlled trials will assess efficacy of denosumab, toremifene, and zoledronic acid to prevent fractures in this setting. Gonadotropin-releasing hormone agonists also increase fat mass, decrease insulin sensitivity, and increase serum lipoproteins. In contrast to the classical metabolic syndrome, however, the phenotype of men during androgen deprivation therapy is characterized by increased high-density lipoprotein cholesterol and preferential accumulation of subcutaneous fat. Gonadotropin-releasing hormone agonists are associated with greater risk of incident diabetes and cardiovascular disease in men with prostate cancer.

SUMMARY

Androgen therapy increases risk of fractures, diabetes mellitus, and cardiovascular disease in men with prostate cancer. Current and planned studies will evaluate strategies to prevent these treatment-related adverse effects.

The microanatomy of trabecular bone in young normal and osteoporotic elderly males

Normally there is a gradual continual loss of cortical and trabecular bone in both men and women as they age. Osteopenia and osteoporosis are conditions in which the loss results in brittle bones that fracture easily. Males with low testosterone and hypogonadism are predisposed to osteoporosis and prevention tends to be overshadowed by the greater problem in postmenopausal women. The ability of the skeleton to resist external forces depends partly upon the amount of bone present and partly upon other factors including cancellous bone microarchitecture. This is examined in iliac crest bone biopsies from idiopathic osteoporotic men, mean age 60+/-12 SD years [n=16]. These were compared with a healthy control group (autopsy samples), mean age 30+/-8.9 years [n=28] with the aim of examining the pattern of cancellous atrophy in male idiopathic osteoporosis. Undecalcified specimens were embedded in methylmethacrylate and prepared for histomorphometry. Sections were analysed using an automated trabecular analysis system (TAS), whereby a binary image was created. Area measurements including the trabecular surface and distance measurements including the trabecular width were made. The binary image was thinned to its medial framework and the node and terminus number as indices of trabecular interconnection were recorded, together with the strut length. Results (median (range)) showed a lower percentage bone volume in the elderly osteoporotic male, 10.2% (5.4-23.1) compared to young normals 25.2% (14.6-43.9), p<0.001. The trabeculae tended to be thinner, 95.7 microm (66.7-170.7) c.f. 120.8 microm (75.8-208.6) and considerably fewer in number, 11.1 (2.1-31.4) c.f. 48.3 (25.4-66.9), p<0.001 per field and in particular the number of nodes, 2.1 (0.15-14) c.f. 40.6 (10.3-74.1) per field and the node: terminus ratio fell to 0.13 (0.01-1.19) c.f. controls 0.98 (0.24-6.69), p<0.001. It was concluded that the pattern of cancellous atrophy in male idiopathic osteoporosis differs from normal aging and resembles that in postmenopausal women. Results using the automated TAS confirm previous observations made manually.

The need for increasing awareness of osteoporosis in men

Awareness of the need to evaluate men for osteoporosis is almost nonexistent among health care providers. Osteoporosis is a silent disorder in both men and women until fracture occurs. Yet, screening for osteoporosis is particularly important in men because fragility fractures are more likely to lead to fatal consequences than in women. Without a diagnosis of osteoporosis, treatment interventions that can prevent fractures in men are not initiated. Advancement of better health outcomes for men at risk for osteoporosis begins with a greater awareness of the need for osteoporosis screening and treatment whenever appropriate. The primary objective of this review article is to report on study findings that document the need for more clinical attention to osteoporosis in men. It is important to know how osteoporosis in men differs from osteoporosis in women, the classification into type 1 and type 2 primary osteoporosis and secondary osteoporosis, and how to measure bone mineral density in men. In addition, there is a great need to develop evidence-based guidelines for the diagnosis and treatment of osteoporosis in men.

Americans are not meeting current calcium recommendations

BACKGROUND

Recent research has raised doubts about the efficacy of calcium supplementation in preventing fractures; however, adequate calcium intake remains important.

OBJECTIVE

Using data from the 1999-2002 National Health and Nutrition Examination Survey, we assessed dietary and supplemental calcium consumption among US men and women according to risk of osteoporosis and stratified by sex, race/ethnicity, and socioeconomic status.

DESIGN

We categorized risk of osteoporosis as high (having an osteoporosis diagnosis or treatment), moderate (aged >50 y), or low (aged 19-50 y). Main study outcomes included milligrams of dietary and supplemental calcium intake, likelihood of meeting national calcium adequate intake (AI) levels, and likelihood of taking supplemental calcium.

RESULTS

Mean (95% CI) total calcium consumption was 944 (846, 1043) mg in the high-risk group, 821 (788, 854) mg in the moderate-risk group, and 846 (812, 871) mg in the low-risk group. Overall, 40% of the sample met the calcium AI amount and 48% reported taking supplemental calcium. After adjustment for daily caloric intake, the greater likelihood of meeting calcium AI levels was associated with [odds ratio (95% CI)] low [versus moderate, 1.5 (1.2, 1.7)] and high [versus moderate, 1.9 (1.3, 2.6)] osteoporosis risk, female sex [1.6 (1.3, 1.8)], non-Hispanic white ethnicity [versus nonwhite, 1.9 (1.7, 2.3)], and education beyond high school [versus less than high school, 1.5 (1.2, 1.9)]. These same factors were also associated with an increased likelihood of taking supplemental calcium, except for a consistent increase with higher osteoporosis risk.

CONCLUSION

Many Americans--particularly men, ethnic minorities, and the socially disadvantaged--are not meeting the current recommendations for adequate calcium intake through diet alone or with supplements.

The diagnosis and treatment of male osteoporosis: Defining, assessing, and preventing skeletal fragility in men

Male osteoporosis is associated with a significant burden in terms of morbidity, mortality, and economic cost. Despite recent advances in the understanding of the male osteoporotic syndrome, the evaluation and treatment of men suffering from osteoporosis remains a clinical challenge. In men with osteoporosis, it remains particularly critical to exclude underlying pathological causes as these are much more likely to be present than in women. There is increasing evidence that the approaches developed to diagnose and treat the disorder in women may be equally useful in men. The available evidence suggests that the anti-fracture efficacy of treatment with alendronate, risedronate, or teriparatide is similar in both sexes. Additional research is warranted to prospectively address the usefulness of BMD measurements to predict fracture risk, to identify those men who are likely to benefit the most from therapy, and to monitor individual responses to therapy.

Bone Related Events in High Risk Prostate Cancer

PURPOSE

We provide recommendations for defining and treating bone related events in high risk prostate cancer.

MATERIALS AND METHODS

A focused literature review was done.

RESULTS

Men with prostate cancer often have osteoporosis and osteopenia even before initiating androgen deprivation therapy. After starting androgen deprivation therapy they experience accelerated bone loss. Bone mineral density is the most common tool to assess the degree of bone loss, although the use of bone turnover markers for this purpose is being actively explored. Bisphosphonates are effective for increasing bone mineral density and treating osteoporosis. The benefits derived from bisphosphonates should be weighed against the adverse effects, including the risk of osteonecrosis of the jaw. Treatment is indicated in patients with prostate cancer with osteoporosis and it may be considered in patients with osteopenia and/or additional risk factors. The time of initiation of therapy and duration of treatment have not been conclusively established.

CONCLUSIONS

Prolonged androgen deprivation therapy results in bone loss and it has a potential to impact quality of life. Additional research is needed to characterize patients who would benefit from therapy and optimize strategies to prevent osteoporosis.

Treatment-related osteoporosis in men with prostate cancer

The intended therapeutic effect of gonadotropin-releasing hormone (GnRH) agonists is hypogonadism, a major cause of acquired osteoporosis in men. Consistent with this observation, GnRH agonists increase bone turnover and decrease bone mineral density, a surrogate for fracture risk. Large claims-based analyses and other retrospective studies provide compelling evidence that GnRH agonists increase risk of clinical fractures. Estrogens play a central role in homeostasis of the normal male skeleton, and estrogen deficiency rather than testosterone deficiency seems to be primarily responsible for the adverse skeletal effects of GnRH agonists. In randomized controlled trials, bisphosphonates (pamidronate and zoledronic acid) and selective estrogen receptor modulators (raloxifene and toremifene) increased bone mineral density in GnRH agonist-treated men. Two ongoing large randomized placebo-controlled studies will prospectively define fracture outcomes in men with prostate cancer and assess the efficacy of novel pharmacologic interventions (AMG162, toremifene) during GnRH agonist treatment.

Osteoporosis among male Saudi Arabs: a pilot study

BACKGROUND

Little attention has been paid to the problem of male osteoporosis in Saudi Arabia. In this prospective study we assessed the prevalence of male osteoporosis among Saudi Arabs.

SUBJECTS AND METHODS

We studied Saudi Arabian males >50 years of age attending outpatient clinics at King Fahd Hospital of the University, Al-Khobar, between 1 May 2005 and 30 January 2006. We determined body mass index (BMI) and tests were done to rule out secondary osteoporosis. All subjects had a bone mineral density (BMD) measurement of the hip area and the lumbar spine using dual energy X-ray absorptiometry (DEXA). A T-score of < or = -2.5 SD that of young, healthy adults was taken as osteoporotic and scores between -1 to -2.5 SD were taken as osteopenic.

RESULTS

One hundred fifteen patients (mean age, 61.8+/-0.75 years; range, 50 to 76 years) had a mean BMI of 24.7+/-0.35 (range, 18.5 to 31). Based on hip scans, the prevalence of osteoporosis was 24.3%. Sixty- four percent were osteopenic. Based on scans of the lumbar spine, the prevalence of osteoporosis was 37.4% and 33.9% were osteopenic. Spinal osteoporosis was more common than hip osteoporosis.

CONCLUSIONS

Our study indicates that the prevalence of osteoporosis among Saudi Arabian males is higher than among Western males. More studies are needed to determine the national prevalence of male osteoporosis. It is recommended that serious measures to be undertaken to prevent male osteoporosis to stop any future epidemic of catastrophic osteoporosis-related fractures.

Osteoporosis: differences and similarities in male and female patients

Osteoporosis is associated with decreased bone strength as a consequence of decreased bone density and altered quality. It is a result of a disruption of balance between bone breakdown and bone formation, caused by increased bone resorption by osteoclasts or without appropriate screening, one's first awareness of the disease is a fracture. It results in increased mortality and significant morbidity. In the last decade, great strides have been made in defining the diagnosis and establishing effective modes of treatment for this disorder. Our current state of knowledge indicates that although this disease affects both sexes, there are clear differences that have clinical importance.

Periodontal status in men with hypergonadotropic hypogonadism: effects of testosterone deficiency

BACKGROUND

The purpose of this clinical study was to evaluate the possible influence of testosterone hormone on common clinical measurements of periodontal disease in men with hypergonadotropic hypogonadism.

METHODS

Twenty-four hypergonadotropic hypogonadal men (H) and 24 systemically healthy men (S) were divided into two groups as chronic periodontitis and clinically healthy controls after clinical examinations and radiographs. The H group consisted of 12 control (H/C) and 12 chronic periodontitis (H/P) patients, and the S group consisted of 12 control (S/C) and 12 chronic periodontitis (S/P) patients. Plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), and clinical attachment loss (CAL) scores were recorded.

RESULTS

The mean of all clinical parameters (PI, GI, BOP, PD, and CAL) were significantly (P<0.05) higher in periodontitis groups (H/P and S/P) than controls (H/C and S/C). There were no significant differences in the PD and CAL scores between periodontitis groups (S/P and H/P). The mean of GI and BOP scores were statistically higher in the H/P group than the S/P group (P<0.05). There was a negative correlation between GI and free testosterone levels (r=-0.794; P<0.05).

CONCLUSION

According to these results, serum testosterone levels may possibly influence periodontal disease in men, and testosterone may have an inhibitory effect on gingival inflammation.

Osteoporosis in men

Osteoporosis is a significant threat to aging bone in men. Thirty percent of hip fractures occur in men; during initial hospitalization and the first year after fracture, the mortality rate is twice that of women. Nevertheless, osteoporosis in men is grossly underdiagnosed and undertreated. The most frequent factors associated with osteoporosis in men are age >75 years, low baseline body mass index (<24 kg/m(2)), weight loss >5% over 4 years, current smoking, and physical inactivity. Osteoporosis in men is either secondary to a primary disease or is idiopathic. It exhibits a bimodal age distribution, with peaks at age 50 years (secondary disease) and at age 70 years (idiopathic). Prevention and early detection currently are the best forms of management. Alone or in combination, calcium, vitamin D, bisphosphonates, and human parathyroid hormone are all effective management options. In the acute setting of fragility fracture, the orthopaedic surgeon is key in identifying patients at risk because the surgeon provides primary care and may initiate prophylactic measures to prevent future fractures.

Utility of biochemical screening in the context of evaluating patients with a presumptive diagnosis of osteoporosis

The ageing population is expected to increase the burden of osteoporosis on the health care system. Secondary causes of osteoporosis are found in a proportion of patients. There is much controversy regarding the best work-up for patients who have been diagnosed as having osteoporosis based on bone mineral density. It is difficult to decide where interventions should be targeted both from a patient's perspective and for cost effectiveness. We evaluated the utility of a standard panel (full blood count, plasma viscosity, plasma protein, electrophoresis, urine Bence Jones protein, thyroid function test, bone profile, fasting lipids and liver function test) of biochemical investigations in 327 consecutive patients (287 females, 40 males) referred to the new patient osteoporosis clinic from April 1999 to March 2000. Patients were characterised after measurement of spinal/femoral neck bone mineral density after a dual energy X-ray absorptiometry (DEXA) scan. There were 88 patients with osteoporosis, 91 with osteopenia, 130 had normal bone mineral density and 20 who did not have a bone scan. No case of multiple myeloma was found in this cohort of patients. There was no difference in the mean plasma viscosity of patients with and without osteoporosis (P=0.182). There was no significant difference in the abnormal urine calcium/creatinine (Ca/Cr ratio) in patients with osteoporosis and those without osteoporosis (P=0.316). There was no significant difference in the prevalence of hypothyroidism (P=0.213) or thyrotoxicosis (P=0.138) in patients with and without osteoporosis. There was no strong correlation between cholesterol concentrations and osteoporosis (r=0.069). We found no utility in performing a myeloma screen. A small proportion of patients had abnormalities of calcium homeostasis or thyroid disease. We recommend that a screening biochemical evaluation should be restricted to calcium/bone profile and thyroid function tests in patients with a presumptive diagnosis of osteoporosis.

Therapy Insight: osteoporosis during hormone therapy for prostate cancer

The intended therapeutic effect of gonadotropin-releasing-hormone (GnRH) agonists is hypogonadism, which is a leading cause of osteoporosis in men. Observations are consistent with this effect: GnRH agonists decrease bone mineral density and increase fracture risk in men with prostate cancer. Estrogens play a central role in homeostasis of the normal male skeleton and evidence suggests that estrogen deficiency is primarily responsible for the adverse skeletal effects of GnRH agonists. The mechanism of treatment-related bone loss involves acceleration of physiologic bone turnover. In small, randomized, controlled trials, bisphosphonates (pamidronate, zoledronic acid) and selective estrogen-receptor modulators (raloxifene, toremifene) increased bone mineral density in GnRH-agonist-treated men. Two ongoing large, randomized, placebo-controlled studies will prospectively define fracture outcomes in men with prostate cancer and assess the efficacy of novel pharmacologic interventions (AMG 162, toremifene) in GnRH-agonist-treated men.