Diagnosis and treatment of Paget's disease of bone: position paper from the Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases (SIOMMMS)

INTRODUCTION

Paget's disease of bone is a focal skeletal disorder causing bone deformities and impairing bone quality. Despite the prevalence of asymptomatic cases is increasing, the progression of the disease can lead to invalidating complications that compromise the quality of life. Doubts on clinical and therapeutic management aspects exist, although beneficial effects of antiresorptive drugs, particularly bisphosphonates are known. However, limited information is available from randomized controlled trials on the prevention of disease complications so that somewhat contrasting positions about treatment indications between expert panels from the main scientific societies of metabolic bone diseases exist. This task force, composed by expert representatives appointed by the Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases and members of the Italian Association of Paget's disease of bone, felt the necessity for more specific and up to date indications for an early diagnosis and clinical management.

METHODS

Through selected key questions, we propose evidence-based recommendations for the diagnosis and treatment of the disease. In the lack of good evidence to support clear recommendations, available information from the literature together with expert opinion of the panel was used to provide suggestions for the clinical practice.

RESULTS AND CONCLUSION

Description of the evidence quality and support of the strength of the statements was provided on each of the selected key questions. The diagnosis of PDB should be mainly based on symptoms and the typical biochemical and radiological features. While treatment is mandatory to all the symptomatic cases at diagnosis, less evidence is available on treatment indications in asymptomatic as well as in previously treated patients in the presence of biochemical recurrence. However, given the safety and long-term efficacy of potent intravenous bisphosphonates such as zoledronate, a suggestion to treat most if not all cases at the time of diagnosis was released.

A comparison of radiographic degeneration features of older Chinese women and older Italian Caucasian women with a focus on thoracic spine

BACKGROUND

Compared with Caucasians, East Asians have a lower incident of back pain, lower prevalence and severity of osteoporotic vertebral fracture and lumbar spine degeneration.

AIM

This study compares radiographic spine degeneration features of older Chinese women (as an example of East Asians) and older Italian women (as an example of Caucasians) with a focus on the thoracic spine.

METHODS

From two population-based epidemiological studies conducted in Hong Kong, China and Rome, Italy, 297 pairs (mean age: 73.6 years) age-matched older community women's lateral spine radiographs were sampled. Existence (or absence) of seven degeneration features were assessed including: (1) hyper-kyphosis, (2) disc space narrowing (T3/T4 ~ T11/T12), (3) osteoarthritic (OA) wedging (T4 ~ T12), (4) generalised osteophyte formation (T4 ~ T12); (5) acquired short vertebrae (T4 ~ T12), (6) Schmorl node (T4 - L5), (7) disc calcification (T4-L5).

RESULTS

Italian women were more likely to have hyper-kyphosis (53.4% vs 25.6%), disc space narrowing (34.4% vs. 17.2%), OA wedging (6.4% vs. 0.67%), Schmorl node (19.5% vs. 4.4%, all P < 0.001). However, there was no statistically significant difference in osteophyte formation (7.7% vs. 9.4%, P > 0.1) and acquired short vertebrae (8.0% vs. 10.4%, P > 0.1). Disc calcification was uncommon among both Chinese and Italians.

DISCUSSION AND CONCLUSION

For the first time, this study documented a lower prevalence of a number of thoracic spine degeneration features among Chinese. This study further affirms the concept of a generally healthier spine in older Chinese relative to older Caucasians. The observed differences may reflect a foundational background influence of genetic predisposition that represents an important line of future research.

Bone Marrow Adipose Tissue Is Increased in Postmenopausal Women With Postsurgical Hypoparathyroidism

CONTEXT

Suppression of bone turnover, greater trabecular volume, and normal-high normal all-site bone mineral density (BMD) are hallmarks of postsurgical hypoparathyroidism (HypoPT). Impairment in the trabecular microarchitecture with possible higher risk of vertebral fractures (VF) in women with postmenopausal HypoPT has also been described. Currently, no data on bone marrow adipose tissue (BMAT) are available in HypoPT.

OBJECTIVE

To assess BMAT by magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (1H-MRS) in postmenopausal women with chronic postsurgical HypoPT.

METHODS

This cross-sectional pilot study, conducted at an ambulatory referral center, included 29 postmenopausal women (mean age 66 ± 8.4 years) with postsurgical HypoPT and 31 healthy postmenopausal women (mean age 63 ± 8.5). Lumbar spine MRI was performed and BMAT was measured by applying PRESS sequences on the L3 body. Lumbar spine, femoral neck, and total hip BMD were measured by dual x-ray absorptiometry (DXA); site-matched spine trabecular bone score (TBS) was calculated by TBS iNsight (Medimaps, Switzerland); VF assessment was performed with lateral thoracic and lumbar spine DXA.

RESULTS

Fat content (FC) and saturation level (SL%) were higher (P <.0001 and P <.001), while water content (W) was lower in HypoPT compared to controls (P <.0001). FC significantly correlated with years since menopause and body weight (P <.05) in HypoPT, while TBS negatively correlated with FC and SL% (P <.05) and positively with residual lipids (RL) and W (P <.05).

CONCLUSION

We demonstrate for the first time that BMAT is increased in postmenopausal women with postsurgical hypoparathyroidism and negatively associated with trabecular microarchitecture.

Conversion of osteoporotic vertebral fracture severity score to osteoporosis T-score equivalent status: a framework and a comparative study of Hong Kong Chinese and Rome Caucasian older women

We explored how the severity of radiological osteoporotic vertebral fracture (OVF) can be converted to the equivalent T-score values.

INTRODUCTION

To perform a study to define what portion of older community women with what severity of radiographic OVF correspond to what low T-score status.

METHODS

There were age-matched 301 Italian community women and 301 Chinese community women (sub-group A, age, 73.6 ± 6.1 years). In addition, Chinese sub-groups B and C included 110 community women (age, 68.9 ± 5.5 years) and 101 community women (age: 82.2 ± 4.3 years), respectively. For each vertebra in women, a score of 0, - 0.5, - 1, - 1.5, - 2, - 2.5, and - 3 was assigned for no OVF or OVF of < 20%, ≥ 20 ~ 25%, ≥ 25% ~ 1/3, ≥ 1/3 ~ 40%, ≥ 40%-2/3, and ≥ 2/3 vertebral height loss, respectively, OVFss was defined as the summed score of vertebrae T4 to L5. OVFss and T-scores were ranked from the smallest to the largest values.

RESULTS

For the Chinese total group (sub-groups A, B, and C together), OVFss = - 1 corresponded to lowest T-score (lowest T-score of lumbar spine, femoral neck, and total hip) of - 3.4 ~ - 3.2. OVFss ≤ - 1.5 corresponded to femoral neck T-score ≤ - 2.5. OVFss = -1.5 corresponded to a mean femoral neck T-score of - 3.0, - 2.6, and - 2.4, among Chinese sub-groups B, A, and C subjects, respectively. For Italians, all cases with OVFss ≤ - 1 had lowest T-score ≤ - 2.5. For cases with femoral neck T-score = - 2.5, 41.7% had OVFss = - 1.5, and 58.3% had OVFss = - 1.

CONCLUSION

For older women, statistically OVFss ≤ - 1 suggests this subject is osteoporotic according to lowest T-score. If using femoral neck T-score, OVFss ≤ - 1.5 qualifies osteoporosis diagnosis.

A software program for automated compressive vertebral fracture detection on elderly women's lateral chest radiograph: Ofeye 1.0

Background

Because osteoporotic vertebral fracture (OVF) on chest radiographs is commonly missed in radiological reports, we aimed to develop a software program which offers automated detection of compressive vertebral fracture (CVF) on lateral chest radiographs, and which emphasizes CVF detection specificity with a low false positivity rate.

Methods

For model training, we retrieved 3,991 spine radiograph cases and 1,979 chest radiograph cases from 16 sources, with among them in total 1,404 cases had OVF. For model testing, we retrieved 542 chest radiograph cases and 162 spine radiograph cases from four independent clinics, with among them 215 cases had OVF. All cases were female subjects, and except for 31 training data cases which were spine trauma cases, all the remaining cases were post-menopausal women. Image data included DICOM (Digital Imaging and Communications in Medicine) format, hard film scanned PNG (Portable Network Graphics) format, DICOM exported PNG format, and PACS (Picture Archiving and Communication System) downloaded resolution reduced DICOM format. OVF classification included: minimal and mild grades with <20% or ≥20–25% vertebral height loss respectively, moderate grade with ≥25–40% vertebral height loss, severe grade with ≥40%–2/3 vertebral height loss, and collapsed grade with ≥2/3 vertebral height loss. The CVF detection base model was mainly composed of convolution layers that include convolution kernels of different sizes, pooling layers, up-sampling layers, feature merging layers, and residual modules. When the model loss function could not be further decreased with additional training, the model was considered to be optimal and termed ‘base-model 1.0’. A user-friendly interface was also developed, with the synthesized software termed ‘Ofeye 1.0’.

Results

Counting cases and with minimal and mild OVFs included, base-model 1.0 demonstrated a specificity of 97.1%, a sensitivity of 86%, and an accuracy of 93.9% for the 704 testing cases. In total, 33 OVFs in 30 cases had a false negative reading, which constituted a false negative rate of 14.0% (30/215) by counting all OVF cases. Eighteen OVFs in 15 cases had OVFs of ≥ moderate grades missed, which constituted a false negative rate of 7.0% (15/215, i.e., sensitivity 93%) if only counting cases with ≥ moderate grade OVFs missed. False positive reading was recorded in 13 vertebrae in 13 cases (one vertebra in each case), which constituted a false positivity rate of 2.7% (13/489). These vertebrae with false positivity labeling could be readily differentiated from a true OVF by a human reader. The software Ofeye 1.0 allows ‘batch processing’, for example, 100 radiographs can be processed in a single operation. This software can be integrated into hospital PACS, or installed in a standalone personal computer.

Conclusions

A user-friendly software program was developed for CVF detection on elderly women’s lateral chest radiographs. It has an overall low false positivity rate, and for moderate and severe CVFs an acceptably low false negativity rate. The integration of this software into radiological practice is expected to improve osteoporosis management for elderly women.

Vertebral Fracture Assessment in Postmenopausal Women With Postsurgical Hypoparathyroidism

CONTEXT

Hypoparathyroidism is a rare endocrine disorder whose skeletal features include suppression of bone turnover and greater volume and width of the trabecular compartment. Few and inconsistent data are available on the prevalence of vertebral fractures (VF).

OBJECTIVE

To evaluate the prevalence of VF assessed by vertebral fracture assessment (VFA) in postmenopausal women with chronic postsurgical hypoparathyroidism.

DESIGN

Cross-sectional study.

SETTING

Ambulatory referral center.

PATIENTS OR OTHER PARTICIPANTS

Fifty postmenopausal women (mean age 65.4 ± 9 years) with chronic postsurgical hypoparathyroidism and 40 age-matched healthy postmenopausal women (mean age 64.2 ± 8.6).

MAIN OUTCOME MEASURES

Lumbar spine, femoral neck, and total hip bone mineral density were measured by dual X-ray absorptiometry (Hologic Inc., USA) in all subjects. Site-matched spine trabecular bone score was calculated by TBS iNsight (Medimaps, Switzerland). Assessment of VF was made by VFA (iDXA, Lunar GE, USA) using the semiquantitative method and the algorithm-based qualitative assessment.

RESULTS

All-site BMD values were higher in the hypoparathyroid vs the control group. By VFA, we observed a 16% prevalence of VF in hypoparathyroid women vs 7.5% in control subjects. Among those with hypoparathyroidism who fractured, 5 (62.5%) had grade 1 wedge, 2 (25%) had grade 2 wedge, and 1 (12.5%) had grade 2 wedge and grade 2 biconcave VF. In the hypoparathyroid group, 57% with VFs and 32% without VFs had symptoms of hypoparathyroidism.

CONCLUSION

We demonstrate for the first time that in postmenopausal women with chronic postsurgical hypoparathyroidism, VFs are demonstrable by VFA despite normal BMD.

Vertebral fracture assessment (VFA) for monitoring vertebral reshaping in children and adolescents with osteogenesis imperfecta treated with intravenous neridronate

PURPOSE

The study was aimed at monitoring vertebral bodies changes with the use of Vertebral Fracture Assessment (VFA) in children and adolescents affected by osteogenesis imperfecta (OI) during treatment with intravenous neridronate.

METHODS

60 children and adolescents (35 males and 25 females; age 1-16 years) with OI type I, III and IV were included in the study. Intravenous neridronate was administered at the dose of 2 mg/kg every 3 months in all patients. Lumbar spine (LS) bone mineral density (BMD) and VFA by dual X-ray absorptiometry (DXA) were assessed every 6 months up to 24 months during treatment. VFA with vertebral morphometry (MXA) was used to calculate the three indices of vertebral deformity: wedging, concavity and crushing. Serum calcium, phosphate, parathyroid hormone (PTH), 25-hydroxy-vitamin D [25(OH)D], total alkaline phosphatase (ALP), bone alkaline phosphatase (BALP) and urinary C-terminal telopeptide of type 1 collagen (CTx) were measured at any time point.

RESULTS

Mean LS BMD values significantly increased at 24 months compared to baseline (p < 0.0001); the corresponding Z-score values were -1.28 ± 1.23 at 24 months vs -2.46 ± 1.25 at baseline; corresponding mean Bone Mineral Apparent Density (BMAD) values were 0.335 ± 0.206 vs 0.464 ± 0.216. Mean serum levels of ALP, BALP and CTx significantly decreased from baseline to 24 months. By MXA, we observed a significant 19.1% reduction of the mean wedging index of vertebral reshaping at 12 months, and 38.4% at 24 months (p < 0.0001) and of the mean concavity index (16.3% at 12 months and 35.9% at 24 months; p < 0.0001). Vertebral reshaping was achieved for 66/88 (75%) wedge fractures and 59/70 (84%) concave fractures, but there were 4 incident mild fractures. Finally, VF rate was reduced at 24 months compared to baseline: 37/710 (5.2%) vs 158/710 (22.2%).

CONCLUSION

Our study demonstrates the utility of VFA as a safe and alternative methodology in the follow-up of children and adolescents with OI.

Imaging technologies in the differential diagnosis and follow-up of brown tumor in primary hyperparathyroidism: Case report and review of the literature

Brown tumors are osteolytic lesions associated with hyperparathyroidism (HPT). They may involve various skeletal segments, but rarely the cranio-facial bones. We report a case of a young boy with a swelling of the jaw secondary to a brown tumor presenting as the first manifestation of primary HPT (PHPT). He was found to have brown tumor located in the skull, as well. Different imaging technologies were employed for the diagnosis and follow-up after parathyroidectomy. We enclose a review of the literature on the employment of such imaging technologies in the differential diagnosis of osteolytic lesions. A multidisciplinary approach comprising clinical, laboratory and imaging findings is essential for the differential diagnosis of brown tumor in PHPT.

•

Brown tumors are associated with more severe hyperparathyroidism (HPT).

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The case of a young patient with primary HPT and brown tumors is reported.

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A multidisciplinary approach should be employed for the differential diagnosis.

•

We reviewed the main radiological characteristics of different types of osteolytic lesions.

Diagnosis and grading of radiographic osteoporotic vertebral deformity by general radiologists after a brief self-learning period

Background

The expanded semi-quantitative (eSQ) osteoporotic vertebral deformity (OVD) classification has minimal, mild, moderate, moderately-severe, severe, and collapsed grades with <20%, 20–25%, >25%–1/3, >1/3–40%, >40%–2/3, >2/3 vertebral height loss respectively. This study evaluates the performance of using this grading criterion by radiology readers who did not have former training in OVD assessment.

Methods

Spine radiographs of 44 elderly women with 278 normal appearing vertebrae and 65 OVDs were selected, with two senior readers agreed the reference reading. Three readers from Italy and three readers from China were invited to evaluate these radiographs after reading five reference articles including one detailing eSQ criteria with illustrative examples. Before the second round of reading, the readers were asked to read an additional explanatory document. For the readers in Italy an additional on-line demonstration was given on how to measure vertebral height loss in another five cases of OVD. Two Chinese readers had a third round of reading after a 90 minutes’ on-line lecture.

Results

The final absolute agreement rate with the reference reading (i.e., exactly the same grading as the reference) ranged between 46.2% to 68.2% for the six readers, and the final relative agreement (with one eSQ grade difference allowed) ranged between 78.5% to 92.5%. The >1 grade disagreement rate was all below 11%, and mostly below 7%. The missed OVD were mostly minimal grade. The rate for missing a ≥ mild OVD was <4.5%, and false positive rate was generally <1.4% among the final reading. If the minimal grade was removed and the remaining gradings were converted to Genant’s semi-quantitative (GSQ) grading, the mean kappa values against the reference reading for SQ grades-1,2,3 were 0.813, 0.814, and 0.916 respectively.

Conclusions

This study demonstrates good performance of the six learner readers for assessing radiographic after a brief self-learning period.

Completely Isolated Enteric Duplication Cyst and Incidental Neuroendocrine Tumor of the Appendix: A Case Report

Patient: Female, 26-year-old

Final Diagnosis: Completely isolated enteric duplication cyst and appendiceal neuroendocrine tumor

Symptoms: Dysmenorrhea

Medication: —

Clinical Procedure: —

Specialty: Oncology • Surgery

Long-term bone mineral density changes after surgical cure of patients with tumor-induced osteomalacia

This paper reports our personal experience filling the gap regarding changes of bone mineral density after surgical treatment in patient suffering from tumor-induced osteomalacia.

INTRODUCTION

No systematic data are available regarding long-term bone mineral density (BMD) changes after surgical cure of patients with tumor-induced osteomalacia.

METHODS

From October 2001 through April 2018, we studied 10 consecutive patients (mean age ± SD, 45.5 ± 13.8 years; 5 males and 5 females) with tumor-induced osteomalacia. We evaluated BMD when initially presented at our Center and after surgical removal of the tumor.

RESULTS

Basal BMD and corresponding Z-score values (mean values ± SD) measured by DXA were as follows: L₁-L₄ = 0.692 ± 0.15 g/cm², Z-score = - 2.80 ± 1.60; femur neck 0.447 ± 0.10 g/cm², Z-score = - 2.66 ± 0.93; total femur = 0.450 ± 0.08 g/cm², Z-score = -3.04 ± 0.85). Furthermore, Trabecular Bone Score (TBS) was evaluated in three patients (basal values, 0.990 ± 0.32). Seven patients were intermittently followed after surgical excision of the tumor while supplemented with cholecalciferol and calcium salts; the remaining three were lost to follow-up. There was a striking increase of BMD values that peaked at 26.7 ± 6.50 months: L₁-L₄ = 1.289 ± 0.247 g/cm², p < 0.001, Z-score + 1.75 ± 1.42; femur neck = 0.890 ± 0.235 g/cm², p = 0.028, Z-score = + 0.50 ± 1.40; total femur = 0.834 ± 0.150 g/cm², p = 0.005, Z-score = - 0.74 ± 1.14. In patients with the greatest bone involvement at lumbar site, there was a striking increase of an average 1.5% (p < 0.01) in respect to baseline Z-score value for each additional month of observation during the first 2-3 years post-surgery. An improvement of trabecular microarchitecture was also documented (TBS, 1.255 ± 0.16).

CONCLUSION

This is the first case series documenting an impressive increase of BMD at both lumbar and femoral sites, together with an improvement of trabecular microarchitecture as documented by TBS. This is the consequence of huge mineralization of the large amount of osteoid tissue after resolution of the disease.

Correction to: Is there a relation between sudden sensorineural hearing loss and white matter lesions?

In the original publication, fifth author's surname was incorrectly published as "Diacinto". The correct surname should read as "Diacinti".

Is there a relation between sudden sensorineural hearing loss and white matter lesions?

PURPOSE

Sudden sensorineural hearing loss (SSNHL) has similarities to conditions with vascular etiologies such as myocardial infarction and cerebral stroke. Thus, it could be considered as an early sign of a vascular disease and not only a specific local condition. Chronic hypoperfusion in the brain districts leads to a chronic ischemic damage, called cerebral small vessel disease (CSVD), detectable with brain magnetic resonance imaging (MRI).

METHODS

The authors used CSVD to establish the presence of vascular risk factors in individuals with SSNHL and used the Fazekas score scale to classify them.

RESULTS

Our study showed that individuals with SSNHL aged between 48 and 60 years have 26% more probability to have a Fazekas score higher than 1 compared to the general population. Individuals younger than 28 years showed a statistically significant negative correlation to have a Fazekas score higher than 0. The higher is the Fazekas score, the less is the probability of hearing recovery. The medium hearing-recovery probability is 46%. This decreases by 16% for every increase of score in the Fazekas scale. In the present study, the recovery probability decreased from 80% in individuals younger than 48 years with a score of 0 to 14% in individuals with a Fazekas scores of 3 and 4.

CONCLUSIONS

The authors assessed a higher prevalence of CSVD compared to the general population in patients aged between 48 and 60 years with SSNHL. Moreover, they assessed that the presence of CSVD is related to a decreased probability of recovery, as it has already been demonstrated for stroke.

Magnetic resonance imaging findings of infectious sacroiliitis associated with iliopsoas abscess: a case report in a young male

Infectious sacroiliitis is an infection of the sacroiliac joint, not easy to diagnose because of its non-specific signs, symptoms and laboratory abnormalities. We describe a case of a 16 year-old male with 5 days' history of fever, abdominal pain, constipation, low-back and left hip pain extended to the left knee associated with sudden inability to walk. In the first place, magnetic resonance imaging (MRI) examination of his sacroiliac joint revealed an enlarged corpuscolated fluid collection near the left iliopsoas muscle, extended to homolateral paravertebral muscles and a little fluid at the left sacroiliac joint. Drainage by aspiration of the iliopsoas abscess was applied; Staphylococcus aureus was found in the aspirated fluid and isolated from the blood too. Therefore intravenous antibiotic therapy was begun. Follow-up MRI exams confirmed the muscle abscess and revealed also a spongy bone edema of the left sacroiliac joint, persisting despite the disappearance of symptoms and the normalization of inflammatory values. It is important to make an early diagnosis of infectious sacroiliitis in order to begin antibiotic therapy as soon as possible, because of the increasing morbidity of infection of sacroiliac joint. In our case MR findings have provided significant orientation towards the final diagnosis of infectious sacroiliitis.

Zenker diverticulum in the right side of the neck resembling a thyroid mass at ultrasound

Zenker’s diverticulum represents the most common form of pharyngo-oesophageal diverticula usually occurring on the left side of the neck. Due to its anatomical proximity to the thyroid, it can mimic a thyroid mass. Here we describe the case of an asymptomatic 49-year-old man referred to the Thyroid Clinic of the Policlinico Umberto I Hospital-“Sapienza” University of Rome for thyroid sonography due to a family history of autoimmune thyroid disease. The patient’s thyroid blood tests did not reveal any abnormalities. The sonographic examination showed a dishomogeneus and hypoechoic thyroid gland. In addition, in the third middle of the right lobe, a mass (with a diameter greater than 26 mm), with heterogeneous internal echogenicity, hypoechoic margins and internal hyperechoic spots was recorded, with no appreciable flow at the Doppler evaluation. The TI-RADS score was 4c. Hence, the patient underwent ultrasound-guided fine-needle aspiration cytology that revealed the presence of squamous cells without cytological atypia, erythrocytes, muscular and vegetable fibres, colonies of bacteria in the absence of inflammatory infiltrate. This was consistent with the diagnostic hypothesis of oesophagus diverticulum, which was confirmed by means of a barium-swallow oesophagography. This case report underlines the possibility that a suspicious thyroid mass may result from a Zenker’s diverticulum, even if located on the right side, especially if the lesion has a heterogeneous echo-texture, a hypoechoic rim and internal hyperechoic spots.

Guidelines for the diagnosis, prevention and management of osteoporosis

Osteoporosis poses a significant public health issue. National Societies have developed Guidelines for the diagnosis and treatment of this disorder with an effort of adapting specific tools for risk assessment on the peculiar characteristics of a given population. The Italian Society for Osteoporosis, Mineral Metabolism and Bone Diseases (SIOMMMS) has recently revised the previously published Guidelines on the diagnosis, riskassessment, prevention and management of primary and secondary osteoporosis. The guidelines were first drafted by a working group and then approved by the board of SIOMMMS. Subsequently they received also the endorsement of other major Scientific Societies that deal with bone metabolic disease. These recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on leading experts' experience and opinion, and on good clinical practice. The osteoporosis prevention should be based on the elimination of specific risk factors. The use of drugs registered for the treatment of osteoporosis are recommended when the benefits overcome the risk, and this is the case only when the risk of fracture is rather high as measured with variables susceptible to pharmacological effect. DeFRA (FRAX® derived fracture risk assessment) is recognized as a useful tool for easily estimate the long-term fracture risk. Several secondary forms of osteoporosis require a specific diagnostic and therapeutic management.

Reliability of vertebral fractures assessment (VFA) in children with osteogenesis imperfecta

The aim of this study is to evaluate the diagnostic accuracy of vertebral fractures assessment (VFA) in comparison with conventional radiography in identifying vertebral fractures in children and adolescents affected by OI. On 58 patients (33 males, 25 females; age range 1-18 years; 41 children and 17 adolescents) with osteogenesis imperfecta (OI type I, n = 44, OI type III, n = 4; OI type IV, n = 10), lateral spine images by radiographs and by dual-energy X-ray absorptiometry (DXA) were acquired. For vertebral fracture diagnosis, plain radiographs were used as "gold standard" and VFA and morphometric X-ray absorptiometry (MXA) were performed. The visualized vertebrae were 738 (97.9%) by radiographs and 685 (90.9%) by DXA of a total of 754 vertebrae from T4 to L4. VFA and MXA identified, respectively, 129 (74%) and 116 (66%) of the 175 vertebral fractures detected by radiographs. Radiographs identified 36 patients with vertebral fractures, VFA 35 and MXA 41 (6 false positives). On a per vertebra basis, radiographs and VFA had elevated agreement (93.9%; k score 0.81, 95% CI 0.76-0.86), that resulted slightly lower for MXA (90.6%; k score 0.72, 95% CI 0.65-0.78). VFA and MXA demonstrated high sensitivity (95.6 and 94.1 %, respectively) while specificity was 100% for VFA and 90.6% for MXA on a per patient basis; the agreement was excellent for VFA (98.3%; k score 0.96, 95% CI 0.89-1.03) and good for MXA (87.9%; k score 0.73, 95% CI 0.55-0.91). The diagnostic performance parameters resulted better for VFA (sensitivity 95.6%; specificity 100%; PPV 100%; NPV 97.2%), than for MXA (sensitivity 94.1%; specificity 85.4%; PPV 72.7%; NPV 97.2%). The results of our study demonstrate the reliability of VFA for diagnosis of vertebral fractures in children with OI suggesting its use as a more safe and practical alternative to conventional radiography.

Effect of risedronate in osteoporotic HIV males, according to gonadal status: a pilot study

The aim of the study was to evaluate the effect of risedronate on bone mineral density (BMD) and bone turnover markers in HIV-infected osteoporotic males, according to their gonadal status. HIV patients were followed up for 24 months and divided into two groups: patients with osteoporosis or osteopenia with fractures (group A, n = 20) and those without (group B, n = 21). Group A and B were further divided according to the presence of reduced androgenizations. Both groups were treated with cholecalciferol 800 I.U. and calcium (Ca) 1,000 mg orally every day for the first 12 months. Risedronate 75 mg for two consecutive days a month orally was then added in group A, for another 12 months. Group B continued treatment with Ca and vitamin D. Every 6 months each patient underwent biochemical evaluation, and BMD measurement. A significant increase in lumbar BMD was observed in HIV males with adequate androgenization after 12 months of risedronate treatment in group A together with a reduction of bone turnover markers. BMD remained stable with a concomitant significant slight reduction of bone turnover markers in group B. Risedronate increased BMD and reduced bone turnover markers to a greater extent in patients with adequate androgenization compared to osteoporotic HIV males with symptomatic hypoandrogenization.

Effect of a single oral dose of 600,000 IU of cholecalciferol on muscle strength: a study in young women

BACKGROUND

The effect of a single large oral dose of vitamin D on muscle function in young people with vitamin D deficiency has not been investigated so far.

AIM

We evaluated the effect of a single oral dose of 600,000 IU of cholecalciferol on muscle strength.

SUBJECTS AND METHODS

Eighteen young women with vitamin D deficiency received a single oral dose of 600,000 IU of cholecalciferol. We evaluated changes in maximal voluntary contraction (MVC) and speed of contraction (S) in response to cholecalciferol by using an hand held dynamometer at 3, 15, 30, 60 and 90 days, compared to baseline.

RESULTS

We observed no significant change in MVC and S values, a significant increase of 25-hydroxyvitamin D [25(OH)D] and 1,25-dihydroxyvitamin D [1,25(OH)2D] and a significant decrease in serum parathyroid hormone (PTH) (p<0.001 for all). A significant correlation was found between MVC and S and serum phosphorus (P) after supplementation (p<0.02 and p<0.05, respectively). Conversely, we observed no association between the parameters of muscle strength and 25(OH)D, ionized calcium (Ca2+), PTH and 1,25(OH)2D.

CONCLUSIONS

A single dose of 600,000 IU of cholecalciferol does not directly enhance handgrip strength in young women with vitamin D deficiency. More studies are needed on the indirect effect of the hormone on muscle.

Adverse events of computed tomography colonography: an Italian National Survey

AIM

To retrospectively study the frequency and magnitude of complications associated with computed tomography (CT) colonography in clinical practice.

METHODS

A questionnaire on complications of CT colonography was sent to Italian public radiology departments identified as practicing CT colonography with a reasonable level of training. The frequency of complications and possible risk factors were retrospectively determined. Responses were collated and row frequencies determined. A multivariate analysis of the factors causing adverse events was also performed.

RESULTS

40,121 examinations were performed in13 centers during the study period. No deaths were reported. Bowel perforations occurred in 0.02% (7 exams). All perforations were asymptomatic and occurred in patients undergoing manual insufflation. Five perforations (71%) occurred in procedures performed following a recent colonoscopy. There was no significant difference between perforations associated with rectal balloon (0.017%) and those that were not (0.02%). Complications related to vasovagal reaction (either with or without spasmolytic) occurred in 0.16% (63 exams). All vasovagal reactions resolved in less than 3h, without any sequelae.

CONCLUSIONS

Perforation rate at CT colonography in Italy is comparable with elsewhere in the world, occurring regardless of the experience of radiology centers. Although the risk is very small, it may not be negligible when compared with the risk of diagnostic colonoscopy.

Diagnostic performance of vertebral fracture assessment by the lunar iDXA scanner compared to conventional radiography

The purpose of this study was to evaluate the diagnostic performance of vertebral fracture assessment (VFA) using the Lunar iDXA scanner. Conventional spinal radiographs and images acquired by dual-energy X-ray absorptiometry (DXA) of 350 subjects (269 females, 81 males) were evaluated by two different readers. We visualized 4,476/4,550 (98.4 %) vertebrae from T4 to L4 on VFA images compared to 4,535/4,550 (99.7 %) on radiographs. Among the visualized vertebrae, 205/4,535 (4.5 %) and 190/4,476 (4.2 %) were identified as nonfracture deformities by reading of radiographs and VFA, respectively. Vertebral fractures (VFs) were 231 in 126 patients and 228 in 125 patients by semiquantitative assessment of radiographs (SQ-Rx) and by VFA, respectively. There was excellent agreement between the two techniques and high diagnostic performance of VFA both on a per-vertebra basis (k score = 0.984, 95 % CI 0.972-0.996, sensitivity 98.68 %, specificity 99.91 %, PPV 98.25 %, NPV 99.93 %) and on a per-patient basis (k score = 0.957, 95 % CI 0.925-0.988, sensitivity 96.83 %, specificity 98.66 %, PPV 97.60 %, NPV 98.22 %). In older patients (≥65 years) affected by moderate or severe osteoarthritis, SQ-Rx and VFA identified 96 VFs and 95 versus 90 vertebral deformities, respectively. This study demonstrates that most vertebrae are evaluable using the iDXA scanner, with improved VFA diagnostic performance even in discriminating mild VFs from vertebral deformities. Therefore, VFA may be appropriate as an alternative to conventional radiography in patients at high risk of VF who are undergoing DXA bone densitometry and in the follow-up of osteoporotic patients on treatment.

Vertebral morphometry by dual-energy X-ray absorptiometry (DXA) for osteoporotic vertebral fractures assessment (VFA)

PURPOSE

This study was done to evaluate the diagnostic accuracy of dual-energy X-ray absorptiometry (DXA) compared with conventional radiography for identifying vertebral fractures.

MATERIALS AND METHODS

A total of 930 postmenopausal women underwent conventional radiography and DXA imaging of the spine. The images were evaluated by two expert skeletal radiologists using the semiquantitative (SQ) method for conventional radiography and the morphometric vertebral fracture assessment (VFA) for DXA.

RESULTS

The SQ method for radiography (SQ-Rx) analysed 99.1% of vertebrae, identifying 442 vertebral fractures; VFA analysed 97.5% vertebrae, detecting 420 vertebral fractures. Agreement between SQ-Rx and VFA reached 98.76%, and the κ-score was 0.96 [95% confidence interval (CI), 0.95-0.98]. Assessing the grading of vertebral fractures, agreement reached 97.5% and the κ-score was 0.841 (95% CI, 0.821-0.891). Considering SQ-Rx method as "gold standard", VFA had a sensitivity of 97.85 % and a specificity of 99.81%. The negative (NPV) and positive (PPV) predictive value for VFA were 99.83 % and 98.15%, respectively. Fractures were identified in 251 (27 %) and 242 (26 %) of patients on SQ-Rx and VFA, respectively. On a per-patient basis, the agreement between the two methods was 97% and the κ-score was 0.95 (95% CI, 0.920-0.968). The diagnostic parameters for VFA were 97.23% sensitivity, 98.86% specificity, 97.60% PPV and 98.84% NPV.

CONCLUSIONS

This study demonstrated that VFA with DXA may reach a high level of accuracy for diagnosing vertebral fractures, suggesting that VFA should be introduced in the screening of individuals with a risk of osteoporosis and in the follow-up of osteoporotic patients receiving treatment.

Vertebral morphometry by X-ray absorptiometry: which reference data for vertebral heights?

INTRODUCTION

The recent improvement in the resolution of dual-energy X-ray absorptiometry (DXA) images enables most vertebral levels to be seen adequately and thus DXA may be a worthwhile alternative to radiologic morphometry for the identification of vertebral fractures (VF). In this multicenter study, we have derived reference data for vertebral heights and their ratios in Italian women using morphometric X-ray absorptiometry (MXA).

METHODS

DXA scans were acquired in 1254 consecutive pre- and postmenopausal women, (mean age 63.7 ± 11.3, range 26-88 yrs), referred to six osteoporosis centers. MXA analysis of these images was performed by the same operator measuring vertebral heights and height ratios from L4 to T4. We calculated measures of central tendency and dispersion of vertebral heights and vertebral ratios using different approaches (mean and standard deviation as well as median and interquartile range of raw data, mean and standard deviation of trimmed data using an iterative algorithm, and mean and standard deviation of not fractured vertebrae).

RESULTS

Independently of the approach that we used, all the measures of central tendency were similar, while significant differences were found when compared with reference ranges in other populations. The vertebral heights of our sample at every vertebral level were significantly smaller than both Rea population and the Lunar reference values, even after normalization. Splitting data according to age groups, there was a decrease in the vertebral heights and ratios between the younger and older women.

CONCLUSIONS

This study demonstrates that reference data for MXA should be population specific and age matched.

A new predictive index for vertebral fractures: the sum of the anterior vertebral body heights

Evaluation of osteoporotic vertebral fracture risk is currently based on measurement of bone mineral density (BMD), but bone strength depends also on bone quality parameters. Aim of this study was to evaluate the validity of a new vertebral morphometric index, the Anterior Vertebral Heights sum (AHs) in discriminating women at high risk of vertebral fracture, comparing its diagnostic accuracy with that of BMD measured at lumbar spine (LS-BMD) and femoral neck (FN-BMD).

MATERIALS AND METHODS

A total of 163 Caucasian post-menopausal women (age range 46-74 years, mean age+/-SD=63.8+/-7.1 years), who did not present prevalent fractures at baseline evaluation, were observed at longitudinal follow-up. X-ray of the thoracic and lumbar spine, LS-BMD and FN-BMD measurements were obtained in all patients at baseline and repeated at the second follow-up visit 18-24 months later (mean 21+/-1.7 months). Radiographs of spine were analysed in order to identify vertebral fractures using a visual semiquantitative method (SQ) and vertebral morphometry as well as by calculating the AHs morphometric index.

RESULTS

During follow-up, 21/163 patients (12.9%) sustained a new vertebral fracture; 95.2% (20/21) of fractured patients but only 4.9% (7/142) of non-fractured women had reduced AHs values. As regarding BMD, 66.6% (14/21) and 61.9% (13/21) of women with incident fracture were osteoporotic at lumbar spine and femoral neck baseline evaluation , whereas among non-fractured women, 38% (54/142) at LS-BMD and 33.1% (47/142) at FN-BMD were osteoporotic . Analyses of Receiver Operating Characteristic (ROC) curves showed that AHs discriminated vertebral fractures almost perfectly (AUC 0.97; 95% CI 0.95-0.99). On the other hand, the AUC for LS-BMD was only 0.73 (95% CI 0.64-0.81) and for FN-BMD was 0.72 (95%CI 0.63-0.80), showing that the diagnostic accuracy of AHs was significantly higher compared to that of LS-BMD (p<0.001) or FN-BMD (p<0.001). A modified Poisson regression model for binary data was used to assess the independent role of AHs in predicting vertebral fracture. The effect of AHs remained statistically significant (p<0.001) after adjusting by FN-BMD, age, weight and body height.

CONCLUSIONS

Results of this study indicate the validity of this new morphometric index in evaluating the risk of osteoporotic vertebral fractures thus suggesting that AHs should be considered a valid parameter in clinical practice to assess the need for primary prevention of vertebral fractures.

Skeletal turnover, bone mineral density, and fractures in male chronic abusers of alcohol

BACKGROUND

Chronic alcohol abuse is a risk factor for osteoporosis and fractures, whose pathogenesis is still unclear. We investigated the influence of alcoholism and other risk factors on calcium and skeletal metabolism, bone mineral density (BMD), and fractures.

MATERIALS AND METHODS

In 51 chronic male alcoholics without liver failure and 31 healthy controls, serum total and ionised calcium, phosphate, creatinine, 25-hydroxy vitamin D (25OHD), PTH, total (ALP) and bone-specific (BALP) alkaline phosphatase, osteocalcin (BGP), carboxy-terminal telopeptide of type I collagen (beta-CTx), osteoprotegerin (OPG) and receptor activator of nuclear factor kappa B ligand (RANKL) were assessed. In patients only, we also measured serum testosterone, 17-beta estradiol, LH, and IGF-I. BMD was measured by dual energy x-ray absorptiometry at lumbar spine (LS-) and femur [neck (FN-) and total hip (TF-)]. Vertebral fractures were identified by a semiquantitative method on thoraco-lumbar spine x-ray, non-vertebral fractures (as life-style factors) by history.

RESULTS

Alcoholics were leaner, had significantly higher ALP and BALP, and lower BGP and 25OHD levels than controls. No significant difference in other calcium and bone metabolism parameters was found. OPG/RANKL ratio was significantly higher in alcoholics. Beta-CTx negatively correlated with abuse duration. OPG positively correlated with daily alcohol assumption and with indexes of liver cytolysis. Though LS-, FN- and TF-BMD of alcoholics and controls did not significantly differ, patients had a much higher prevalence of vertebral fractures. The same was found considering both vertebral and non-vertebral fractures.

CONCLUSIONS

Ethanol-induced skeletal damage seems mainly dependent on negative effects on bone formation. Lifestyle factors and traumas likely contribute to the high fracture incidence of alcohol abusers, independently of BMD.

Cyclical changes of vertebral body heights and bone loss in healthy women after menopause

Annual changes in vertebral body heights (VHs) and lumbar bone mineral density (LBMD) were evaluated in 120 healthy pre- and post-menopausal women aged 45-74 years. Subjects were divided into groups according to menstrual status and years since menopause (YSM). Vertebral heights were evaluated, using radiological morphometry as the sum of anterior vertebral body heights (AVHs) from T4 to L5 at baseline and exactly 12 months later. Results indicate that the sum of VHs is inversely correlated with advancing age, and the decrease in VHs is not a constant process over time but rather exhibits cyclical damping oscillations. When log-linear trend of VH decrease was transformed into a constant considering annual percentage changes, the presence of a cyclical component of 7 years was evident. Employing a harmonic regression model, the cyclical component was also statistically significant on baseline data. The cyclical decrease of VHs corresponds to an analogous cyclical behavior of LBMD values. These results suggest that a lack of estrogen acts as a synchronizer on bone remodeling, triggering a latent cyclical rhythm of bone loss, accompanied by cyclical bone microarchitecture deterioration and consequent vertebral body deformities, which after menopause persists throughout life. The existence of a chronobiological rhythm of bone loss and trabecular bone strength reduction at vertebral level after menopause, if confirmed, could have important clinical implications.

Abdominal CT findings may suggest coeliac disease

BACKGROUND

Coeliac disease is the most common gastrointestinal immunological disorder in the western countries. Many adult patients present non-specific symptoms and signs of malabsorption such as chronic diarrhoea, anaemia, weight loss and abdominal distention. In non-specific and doubtful conditions, computed tomography is often the first medical examination performed. In a clinical practice, a critical review of computed tomography signs is therefore mandatory.

AIMS

To evaluate the abdominal computed tomography findings, which are useful to suggest the presence of coeliac disease in adult patients.

PATIENTS AND METHODS

The computed tomography studies of 28 coeliac patients were reviewed, looking for any intestinal and extraintestinal abnormality. The computed tomography findings evaluated were: abnormalities of intestinal fold pattern, bowel dilatation, fluid and air excess, duodenal abnormalities, intestinal intussusception, bowel wall thickening, lymphadenopathy, ascites, intestinal stenosis, mesenteric vascular changes. The abdominal computed tomography of a group of 30 normal subjects was also analysed.

RESULTS

Intestinal fold pattern abnormalities were seen in 23/28 patients. Intestinal dilatation was seen in 21/28. Fluid excess in 18/28 and lymphadenopathy was seen in 12/28 patients; engorgement of mesenteric vessels in 7/28. Bowel wall thickening was observed in 6/28 patients and transient intussusception was observed in 6/28 patients. Increased air content within the bowel in 4/28 and ascites in 2/28 patients. Bowel dilatation together with fluid excess was observed in 18/28 patients. None of the above mentioned abnormalities abnormalities were seen in normal subjects.

CONCLUSIONS

Data of the present study show that several abdominal computed tomography findings may be seen in coeliac adult patients; these findings should be taken into consideration with a high in level of suspicion by radiologists, to avoid diagnostic delay and unnecessary diagnostic and therapeutic procedures.

Type II benign osteopetrosis (Albers-Schönberg disease) caused by a novel mutation in CLCN7 presenting with unusual clinical manifestations

A 16-year-old male patient with type II autosomal dominant benign osteopetrosis (ADO) was genotyped and found to harbor a novel mutation in exon 25 of the gene encoding for the osteoclast-specific chloride channel, CLCN7, inherited from the father, who was asymptomatic. The patient had normal biochemical findings and acid-base balance, except for increased serum levels of creatine kinase, lactic dehydrogenase, and the bone formation markers bone alkaline phosphatase isoenzyme, osteocalcin and N-terminal type I collagen telopeptide/creatinine ratio. Unusual generalized osteosclerosis was observed together with a canonical increase in vertebral and pelvis bone mass. An affected first grade cousin presented with normal biochemical findings and a milder osteosclerotic pattern of the pelvis. At the cellular level, cultured osteoclasts from the patient showed increased motility, with lamellipodia, membrane ruffling and motile pattern of podosome distribution, all of which could have contributed to functional impairment of bone resorption. The present report documents a novel mutation of the CLCN7 gene causing osteopetrosis in a radiologically uncertain form of the diseases, with apparent incomplete penetrance.

Adrenomedullin concentrations are elevated in plasma of patients with primary hyperparathyroidism

The aim of the study was to evaluate plasma adrenomedullin (AM) concentration in primary hyperparathyroidism (PHP) and its effect on the regulation of blood pressure. Forty-one patients with PHP (25 normotensive and 16 hypertensive), and 31 healthy subjects (HS) were included in the study. As expected the total and ionized calcium and i-PTH serum levels were significantly higher in patients with PHP than in HS (P <.001). No significant difference was found in calcium-phosphorus metabolism parameters between normotensive and hypertensive PHP patients. Serum i-PTH levels correlated positively with systolic blood pressure (SBP) (r = 0.510; P <.02), diastolic blood pressure (DBP) (r = 0.586; P <.01) and heart rate (HR) (r = 0.486; P <.043) only in hypertensive PHP patients. Overall, mean plasma AM concentrations were significantly higher in PHP patients (16.1 +/- 7.9 pg/mL) than in HS (11.3 +/- 4.8 pg/mL) (P <.003) and correlated with i-PTH (r = 0.430; P <.005). However, in hypertensive PHP patients plasma AM levels (22.5 +/- 4.7 pg/mL) were higher than in normotensive PHP patients (11.6 +/- 1.8 pg/mL) (P <.001) and correlated with DBP (r = 0.902, P <.0029). In HS no correlation was found between plasma AM values and biohumoral, hormonal, or hemodynamic parameters. In conclusion, we demonstrated that in patients with PHP, plasma AM concentrations are increased and correlate with i-PTH and blood pressure values. We suggest that increased AM levels could be a compensatory factor in the defence mechanism against further blood pressure elevation.

Cyclical behavior of bone remodeling and bone loss in healthy women after menopause: results of a prospective study

Annual changes in lumbar bone mineral density (LBMD) and bone remodeling markers were measured in 238 healthy pre- and postmenopausal women, aged 45-74 years. The subjects were divided into groups according to their menstrual status and years since menopause. The results obtained indicate that bone loss is not a constant process over time but rather exhibits cyclical damping oscillations. When the log-linear trend of LBMD decrement was transformed into a constant by considering annual percentage changes, the presence of a cyclical component of 7 years was evident. By employing a harmonic regression model, the cyclical component was also statistically significant on baseline data. The cyclical behavior of LBMD decrement corresponded to an analogous behavior of the bone remodeling markers. These results suggest that a lack of estrogen acts as a synchronizer on bone remodeling by triggering a latent cyclical rhythm of bone loss that persists throughout life after menopause. The existence of a chronobiological rhythm of bone loss starting after menopause, if confirmed, could have important clinical implications.

Plasma adrenomedullin concentrations in patients with adrenal pheochromocytoma

BACKGROUND

The hypotensive peptide adrenomedullin was first isolated in extracts of human pheochromocytoma. There is, however, no information available on the behaviour of circulating adrenomedullin or on the correlation with catecholamines in patients with pheochromocytoma.

OBJECTIVES

1) to investigate whether plasma adrenomedullin levels were changed in 10 patients with pheochromocytoma when compared to 21 healthy subjects and 16 patients with essential hypertension; 2) to determine whether or not adrenomedullin has a counter-regulatory role in catecholamine excess in pheochromocytoma or is responsible for hemodynamic modifications before and after tumour resection; 3) to determine tissue distribution of iradrenomedullin in the pheochromocytoma.

METHODS

Plasma adrenomedullin and catecholamine levels were measured in all patients with pheochromocytoma before and four weeks after tumour removal. In the four patients undergoing resection of tumours, plasma levels of adrenomedullin were measured at different time-points during surgery.

RESULTS

The mean plasma adrenomedullin concentrations ( SD) in patients with pheochromocytoma (37.9 +/- 6pg/ml) were significantly higher (p<0.0001) than those in normal subjects (13.7 +/- 6.1 pg/mI) and patients with essential hypertension (22.5 +/- 9.lpg/ml). Adrenomedullin levels correlated with plasma noradrenaline (r = 0.516, p = 0.0124). In all patients with pheochromocytoma, plasma adrenomedullin concentrations decreased after removal of tumours (from 37.9 +/- 6 to 10.9 +/- 4.6 pg/ml; p < 0.0001). In the four patients studied during surgery, baseline plasma adrenomedullin and noradrenaline levels were markedly elevated, and increased significantly with tumour manipulation, decreasing 24 hours after operation. Adrenal medulla cells surrounding the pheochromocytoma site stained for ir-adrenomedullin, whereas only isolated cells of pheochromocytoma stained for the peptide.

CONCLUSIONS

This study demonstrates that circulating adrenomedullin is increased in pheochromocytoma, and is also correlated with plasma noradrenaline levels. Adrenomedullin may represent an additional biochemical parameter for clinical monitoring of patients with pheochromocytoma.

[Vertebral morphometry: evaluation of osteoporosis-caused fractures]

PURPOSE

To compare visual reading of spine radiographs and quantitative morphometric approach for assessing the prevalence of vertebral fractures in postmenopausal osteoporosis.

MATERIAL AND METHODS

In 473 postmenopausal women afferent to our Centre of Osteoporosis under-went lateral thoracic and lumbar spine radiograph to identify vertebral fractures and dual energy X-ray absorptiometry (DXA) to measure bone mineral density (BMD) of the lumbar spine (L1-L4). Osteoporosis was defined according to the World Health Organization (WHO) guidelines. To identify vertebral fractures the radiographs were visually analyzed by two radiologists; a woman was judged as fractured only if both readers independently found at least one vertebral fracture on her films. Then the spine radiographs were digitized by means of a scanner to perform quantitative vertebral morphometry (QVM) using specific software. An expert operator manually located the calipers on the vertebral bodies from T4 to L5 and the computer automatically calculated the anterior, middle and posterior vertebral heights and their ratios. A vertebral fracture was defined by morphometry as a reduction by at least 20%, with an absolute decrease of at least 4 mm, in one of three height ratios of any vertebral body compared to the corresponding reference ratio for fertile women.

RESULTS

Visual reading by radiologists detected 9.5% (45/473) women with vertebral fractures and QVM detected 13.7% (65/473) with statistical significance (p < 0.001). In the 75-80 years age group the prevalence of vertebral fractures reaches the maximum value, 26.3% by visual reading and 36.8% by QVM. Among fractured women, 34 were osteoporotic by DXA; 11 women found fractured by visual reading and 21 by QVM were osteopenic women, with bone mineral densities between -1 and -2.5 SD of the T-score.

CONCLUSION

This study showed that quantitative assessment of spine radiographs by vertebral morphometry is an objective method that allows to identify a larger number of vertebral fractures compared to visual inspection. This is very important not only for epidemiological studies, but also for clinical use because a previous vertebral fracture increases the risk of subsequent fractures significantly. Therefore, to improve the risk assessment of vertebral fractures for osteoporotic patients it is necessary to combine the use of QVM and BMD.

Annual skeletal balance and metabolic bone marker changes in healthy early postmenopausal women: results of a prospective study

The aim of this study was to establish the duration and annual rate of menopause-related bone loss and to investigate the relationship between bone turnover and bone loss in early healthy postmenopausal women. The rate of change in bone mineral density (BMD) at the lumbar spine and in bone turnover was measured twice at the exact interval of 12 months by dual-energy X-ray absorptiometry (DXA) and by the determination of plasma alkaline phosphatase levels (ALP) and fasting urinary hydroxyproline/creatinine ratio (OHPr/Cr), respectively, in 123 healthy premenopausal and postmenopausal women 45-60 years of age. The subjects were divided into nine groups according to their menstrual status and years since menopause (YSM). Annual bone loss at the lumbar spine of women who were menopausal for 1, 2, 3, 4, and 5 years was -2.62 +/- 0.37 (95% confidence interval -3.66, -1.58), -3.87 +/- 0.96 (-6.02, -1.73), -2.50 +/- 0. 37 (-3.29, -1.70), -2.86 +/- 0.73 (-4.44, -1.27), and -1.54 +/- 0.41 (-2.42, -0.66), respectively, and was significantly less than zero. But, the annual bone loss of women who were premenopausal or menopausal for 6, 7, and 8 years was -0.76 +/- 0.60 (-2.04, +0.53), -1.16 +/- 0.68 (-2.61, +0.29), 0.24 +/- 0.48 (-0.78, +1.26), and 0. 16 +/- 0.63 (-1.18, -1.49), respectively, and was not significantly different from zero. These results demonstrate that the early hormone-dependent bone loss commences in the first year after menopause and is arrested within 6 years after the onset of menopause. The overall bone loss for this phase is estimated to be approximately 15%. Annual change in ALP and OHPr/Cr seems to indicate that bone resorption prevails on bone formation in the first 2 YSM, whereas osteoblastic activity relatively prevails from YSM 3 to YSM 5, which explains the progressive repairing of the imbalance between bone resorption and formation.

Relationship between spine bone mineral density and vertebral body heights

The aim of this study was to investigate the correlation between lumbar spine bone mineral density (LS-BMD) and the vertebral body heights with advancing age and years since menopause. One hundred and sixty-three women ages 39-74 years (77 normal premenopausal, ages 39-54, and 86 normal postmenopausal, ages 46-74 years) were studied. LS-BMD was measured by dual energy X-ray absorptiometry. Vertebral heights were evaluated, using morphometry, as the sum of anterior (AHs), middle (MHs), and posterior (PHs) vertebral body heights from T4 to L5. The AHs/PHs ratio at the same level was also calculated. AHs, MHs, PHs, and AHs/PHs ratio directly correlated with LS-BMD; the correlations are AHs r = 0.80, P < 0.0001, MHs r = 0.75, P < 0.0001, PHs r = 0.76, P < 0.0001, and AHs/PHs r = 0.66, P < 0.001. Both LS-BMD and AHs are inversely correlated with age, and the regressions fit with both linear and cubic curves. The statistical significance of the correlations persists while maintaining age constant. The linear regression curve of AHs with age indicates that the spine height decrement rate is 2.12 mm/year, corresponding to 7.4 cm in 35 years. AHs decreases immediately after menopause fitting with a cubic curve model, with a decrement rate of about 3 cm in the first 5 years after menopause. We conclude that the measurement of the sum of vertebral body heights could usefully integrate LS-BMD evaluation in the clinical and epidemiological investigation of osteoporosis.

Doppler sonography of the superior mesenteric artery in Crohn's disease

OBJECTIVE

The aim of this study was to evaluate blood flow in the superior mesenteric artery (SMA) in patients with active and inactive Crohn's disease (CD) using Doppler sonography to dynamically assess the changes of resistance in both fasting and postprandial states.

SUBJECTS AND METHODS

Doppler sonography of the SMA was performed on 15 patients (mean age, 38 +/- 4 years) with active CD and on 15 patients (mean age, 41 +/- 5 years) with inactive CD. Imaging was performed at both fasting and 15 min after an 1890-kJ meal. A preliminary examination of 10 healthy volunteers with no signs of intestinal disease (mean age, 28 +/- 2 years) was necessary to define the parameters of normality. Because we wanted to express the postprandial resistive change in the SMA, we introduced a parameter called resistive difference (RD), defined as the mathematic difference between the resistive index measured at fasting (highest value) and measured at 15 min after the meal (lowest value).

RESULTS

By evaluating the relationship between the RD and extension of disease, we found a direct correlation between progressive extension of disease and reduction of the RD in patients with active CD (correlation coefficient, .98) whereas we found no such correlation in patients with inactive CD (correlation coefficient, .05).

CONCLUSION

We believe that Doppler sonography of the SMA is a promising noninvasive method to detect inflammatory disease of the small bowel, to evaluate its extension, and to document resolution of disease after therapy.

Computed tomography of bowel wall in patients with Crohn's disease: relationship of inflammatory activity to biological indices

Bowel wall thickening in Crohn's disease can be demonstrated by Computed Tomography. The aim of this investigation was to correlate different patterns of bowel wall thickening, detected with Computed Tomography, with serological parameters of activity of Crohn's disease. Thirty-eight patients (24 males, 14 females, aged 21 to 62 years) were studied. Patients were divided into 3 groups according to Computed Tomography appearance of bowel wall: 1) homogeneous symmetrical thickening of wall; 2) bowel showing a layer of submucosal low attenuation; 3) scarred narrowing of wall producing stenosis. A patient was considered to have biochemically active disease if at least 2 of the following parameters were abnormal: ESR, C-reactive protein, seromucoids, serum albumin, serum alpha-2 globulin. The first group comprised 20 patients (16 active disease, 4 inactive) and the second group 13 (all inactive); the 2 groups showed a significant difference (Fisher exact test: p < 0.0005) in biological activity. Since only 5 patients belonged to the third group (3 active, 2 inactive disease), no definite conclusion can be drawn on the possible correlation between this Computed Tomography pattern and activity of disease. Results shows a correlation between Computed Tomography patterns of bowel wall disease and biochemical activity of Crohn's disease.

[A digital radiology method for assessing vertebral osteoporosis]

The radiologic identification of vertebral fractures is usually subjective and reproducibility is poor. This paper describes a new digital radiologic method to perform vertebral morphometry, i.e. osteoradiometry (ORM). Lateral radiographs of the thoracic and lumbar spine were obtained in 50 premenopausal women and digitalized by means of a video camera. A special computer software enables to calculate the anterior (Ha), middle (Hm), and posterior (Hp) heights of vertebral bodies (T4-L5) and the morphometric indices of vertebral fractures. ORM reproducibility was assessed by comparing repeated measurements made by two radiologists: the intra- and interobserver variation coefficients (CV) were respectively 1.5% and 2.3% for Hp; 1.3% and 2% for Hm; 1.4% and 2.1% for Ha. The normal range for vertebral dimensions was therefore established. The anterior and posterior heights increased from T4 to L2, but for L3-L5 the posterior height was lower than the anterior height (Ha/Hp > 1). Vertebral heights positively correlated with the standing heights of the subjects (r = 0.2, p < 0.05). Weight and the body mass index (BMI) were not correlated with vertebral heights. These normal values, compared with those found in osteoporosis patients, will allow to assess ORM diagnostic efficacy in identifying vertebral fractures.

Aging changes in vertebral morphometry

We analyzed the vertebral morphometry of healthy premenopausal women and their changes with age and menopause in order to better define the reference population for the clinical and epidemiological evaluation of vertebral fractures. Vertebral morphometry has been performed on lateral thoracic and lumbar spine films from 50 premenopausal and 76 postmenopausal normal women, age range 39-74 years. Vertebral heights and the anterior height/posterior height ratio are significantly lower in postmenopausal compared with premenopausal women. Vertebral anterior height decreases about 1.5 mm/year, whereas middle and posterior height decreases about 1.3 and 1.2/mm year, respectively. A statistically significant reduction of vertebral heights by around 1 mm/vertebra was observed in postmenopausal (n = 16) compared with premenopausal women (n = 20) of the same age (P < 0.05). The results demonstrate that vertebral heights are lower with advancing age and menopause and that the vertebral heights difference in elderly people is not only the consequence of a cohort effect. The results also contribute to better defining the reference population to be chosen for evaluating vertebral deformation.

Effect of endogenous cholecystokinin on postprandial gallbladder refilling. Ultrasonographic study in healthy subjects and in gallstone patients

The postprandial release of cholecystokinin (CCK) regulates gallbladder (GB) contraction but little is known about the role, if any, of the still-elevated CCK blood levels on subsequent GB refilling. To assess the role of CCK in GB refilling, a CCK-receptor antagonist, loxiglumide, or saline were infused intravenously in a random double-blind fashion after the ingestion of a liquid test meal in 16 healthy subjects. An identical study protocol was performed in 10 GB "contractor" patient with radiolucent stones to ascertain whether the reported reduced CCK effect on GB emptying also affects GB refilling. GB volumes were assessed ultrasonographically in the fasting state and for 150 min at 15-min intervals after meal ingestion. GB volumes during postprandial refilling were significantly greater during loxiglumide than placebo infusion (P < 0.01), but they did not differ between gallstone and control subjects. In conclusion, postprandial endogenous CCK has a relevant role in delaying GB refilling, and this effect is not altered in patients with radiolucent gallstones.

Intravariceal pressure measurement in cirrhotic patients: is it a reliable technique?

The aim of the present study is to evaluate in both "in vitro" and clinical conditions the reliability of the method for measuring the oesophageal varices pressure by means of a sclerosing needle. The perfusion system was validated "in vitro", comparing the tracings obtained with two different perfusion apparatus, with two different perfusional agents and with the needle either completely or partially inserted in a venous catheter perfused with saline solution, either in the same direction as the flow or the opposite one. The clinical validation was conducted on 14 cirrhotic patients with II to IV grade oesophageal varices according to Dagradi's classification. During endoscopy, the intravariceal and oesophageal pressures were measured using a sclerosing needle, perfused with hydrosoluble contrast medium. Once the intravariceal pressure measurement was completed, an X-ray film of the chest was performed. The data were evaluated considering the absence of visible contrast medium as evidence of correct intravariceal needle position, and the presence of a roundish image as evidence of paravariceal insertion of the needle. The presence of respiratory oscillations and intravariceal pressure values were verified in manometric tracings and were compared with radiological findings. The "in vitro" tests showed no differences in the pressure recording obtained using different pumps, different perfusion agents and with different manners of inserting the needle. Only twenty-eight of the manometric recordings were considered adequate for evaluation in clinical conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Efficacy of L-thyroxine (L-T4) therapy on the volume of the thyroid gland and nodules in patients with euthyroid nodular goiter (ENG)]

The efficacy of treatment with TSH suppressive doses of L-thyroxine was evaluated by echography in 35 patients with euthyroid nodular goiter. Patients have been subdivided in two groups comparable for sex age and size of the goiter. Sixteen patients were treated for nine months with suppressive doses of thyroxine and nineteen were followed without therapy as control. Patients in treatment were then followed up for additional 9 months without therapy. The mean decrease of thyroid volume at nine months was 25% (27 +/- 10 ml vs 20 +/- 8 ml; p < 0.01). After discontinuation of treatment thyroid volume increased and had returned to base line values after nine months of follow up. In the control group mean thyroid volume had increased by 17.7% at nine months (28 +/- 17 vs 33 +/- 19 ml; p < 0.001). Thyroid nodules in response to thyroid hormone treatment showed a variable behaviour: 30.7% (4/13) of the nodules responded to the therapy with a reduction > to 25% at the ninth month; the remaining nodules were insensitive to the therapy. In conclusion suppressive thyroxine treatment is effective in reducing the goiter, nodules instead are only in part sensitive to the treatment. Thyroxine therapy of euthyroid nodular goiter must be followed for long term since upon thyroxine discontinuation there is a prompt reappearance of the goiter.

Effects of salmon calcitonin on the bone loss induced by ovariectomy

We present the results of a 12-month clinical study assessing the effects of synthetic salmon calcitonin (sCT) on a group of fertile white women who had undergone ovariectomy for uterine fibromatosis. The study was performed to verify whether CT can prevent the loss of bone mass and the changes in calcium-phosphorus metabolism associated with acute estrogen deficiency. The study consisted of an initial double-blind phase of 6 months, followed by a 6-month open period. Treated patients were given 100 MRC U of synthetic salmon CT injected i.m. in the morning, every other day, starting on the 7th day after the operation and continued for 12 months. Control patients received a placebo injection for the first 6 months; subsequently, they too were treated with sCT i.m. every other day for 6 months at the same dose as the 12 month-treated group. All patients received 500 mg of elementary calcium p.o., b.i.d. Bone mineral content (BMC) was measured at the extreme distal radius of the nondominant arm by a dual photon bone densitometer which utilizes two radio nuclides, 241 Am and 125 I, with energies of about 60 and 30 KeV. Biochemical parameters of the calcium-phosphorus metabolism were also measured. After 12 months of study, no significant changes of BMC were observed in the 12 months sCT treated group, while control patients, treated 6 months after the ovariectomy, showed a significant decrease in BMC values.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of intestinal giardiasis associated with immunoglobulin deficiency and intestinal lymph node hyperplasia]

The authors recall the main etiopathogenetic, immunological and clinical features of Giardiasis; they report on a patient suffering from intestinal Giardiasis associated with immunoglobulin deficiency and nodular lymphatic hyperplasia of the gut. They report the results of medical therapy.

[Tubercular Addison's disease with high titers of microsomal thyroid antibodies and reduced thyroid function reserve]

This case reports deals with a male patient, white, aged 51, bricklayer, tobacco smoker. At 43 years old a tubercular epididimite was surgically treated with orchiectomy. Recently, the reports marked weakness, weight loss, headache, vertigo, hypotension. On admittance to the hospital, hyperpigmentation was also present. Previous therapy (cortisone acetate 40 mg/die), was suspended, clinical investigations showed impaired adrenal and thyroidal functions; antimicrosomal antibodies were also present. Therefore therapy with cortisone acetate (25 mg x 2/die, 9-alpha-fluorohydrocortisone 0.1 mg/die and L-thyroxine 100 mcg/die) was instituted with marked improvement of the patient's conditions. This case reports highlights the importance of proceeding with complete investigations on the system, even when dealing with a tubercular Addison's disease.

Autonomic neuropathy and secondary hyperparathyroidism in uraemia

To evaluate the relationship between autonomic neuropathy, and biochemical and X-ray parameters of secondary hyperparathyroidism, we examined 19 predialysis and 24 haemodialysis non-diabetic uraemic patients. Autonomic neuropathy was assessed using four tests: deep breathing, Valsalva manoeuvre, lying to standing, and postural hypotension. Serum Ca, Ca2+, P, Mg, alkaline phosphatase, iPTH, and osteocalcin were assayed. Hand X-ray was obtained to evaluate acro-osteolysis (score A) and subperiosteal resorption (score B). Ten predialysis patients (52%) and 15 haemodialysis patients (62%) showed one or more abnormal autonomic tests. Age, dialysis duration, and biochemical parameters of secondary hyperparathyroidism did not differ significantly in uraemic patients with and without abnormal autonomic tests. Furthermore, there was no significant relation between autonomic tests and iPTH or osteocalcin. Score A and score B was significantly greater in patients with abnormal tests than in patients without (P less than 0.009 and P less than 0.025). When predialysis and haemodialysis patients were considered separately the correlation between score A, score B, and autonomic neuropathy was confirmed only in haemodialysis patients. In conclusion, autonomic neuropathy does not seem to be related to the biochemical parameters of secondary hyperparathyroidism, while it appears significantly associated with the radiological signs of osteodystrophy, suggesting a possible pathogenetic linkage between autonomic neuropathy and secondary hyperparathyroidism.