Bone mass and vitamin D levels in women with a diagnosis of fibromyalgia

No differences in either bone mineral density or serum 25OHD levels have been found between 205 women with fibromyalgia (both pre- and postmenopausal) and their controls. However, a lack of the expected 25OHD summer rise was observed in patients.

INTRODUCTION

Contradictory data have been published regarding a possible association between fibromyalgia and osteoporosis or hypovitaminosis D. Most studies, however, have been performed in small size samples and have excluded postmenopausal women. We decided to study this association in a larger sample of fibromyalgia patients including both pre- and postmenopausal women.

METHODS

Two hundred five patients were recruited from a clinic specializing in fibromyalgia and 205 healthy controls were enrolled from the census of a Primary Care Center. Controls were matched with patients by age and the time of the year they were included in the study. Bone mineral density (BMD) was measured by DXA. Serum 25OHD, iPTH, P1NP, and CTX were also determined.

RESULTS

BMD was similar in both groups (lumbar spine, 0.971 ± 0.146 g/cm(2) in patients and 0.970 ± 0.132 g/cm(2) in controls; femoral neck, 0.780 ± 0.122 g/cm(2) and 0.785 ± 0.117 g/cm(2), respectively). 25OHD levels were also similar: 23.0 ± 9.5 ng/ml and 24.1 ± 9.6 ng/ml. However, while controls showed the usual summer rise in 25OHD, fibromyalgia patients did not. PTH did not show seasonal changes, but on average was higher in patients (51 pg/ml vs. 48 pg/ml; p = 0.034). P1NP or CTX were similar in both groups.

CONCLUSIONS

No differences in BMD were found between patients and controls. As for 25OHD, a lack of its expected summer rise was observed. It is doubtful whether this has any homeostatic consequence. We consider that the association reported in other studies is merely circumstantial, and not due to the intrinsic characteristics of these disorders.

Current status of General Pathology training in Spain

BACKGROUND AND OBJECTIVES

One of the core subjects in university training of the physicians has been General Pathology. Responsibility for this has historically fallen on Internal Medicine specialists. However, we are unaware if this situation is currently maintained.

METHODS

A questionnaire was sent to the coordinators of the subject of the 39 Spanish medical schools to know, among other things, the current denomination of the subjects (traditionally known as «General Pathology»), number of credits, teaching activities included in the subject and number and specialty of the professors responsible for it. Some data from the medical schools that did not respond were obtained from their web pages.

RESULTS

A total of 28 of the 39 (72%) medical schools existing in Spain answered the survey. The current denomination of the subject «General Pathology» varied greatly. The mean number of credits (one credit=20-25 h) was 11.2 (range 3 to 29). In 22 of 34 schools (65%), the subject was taught in the third year of the studies, but in 21% of the schools, it was partially and in 15% of the schools, totally, taught in the second year. More than half of the professors (54%) who taught the subject were Internal Medicine specialists, although this responsibility was shared with other specialists in a large proportion.

CONCLUSIONS

Teaching of General Pathology shows a marked heterogeneity that does not seem to be due to teaching or pedagogic criteria among the different schools of Spain. These facts may be due to less presence in the university setting of Internal Medicine compared to other specialties.

Osteoprotegerin and bone mass in squamous cell head and neck cancer patients

Osteoprotegerin (OPG) is considered one of the main regulators of bone remodeling. Various patterns of serum OPG levels have been described in different types of tumors. We undertook this study to determine serum OPG levels in patients with squamous cell head and neck cancer (SCHNC), analyzing their relationship with other metabolic bone parameters and bone mineral density (BMD), as well as the possible influence of chemotherapy. Forty male patients with localized SCHNC were studied, and their results were compared with those of 40 healthy male controls. The type of treatment followed by each patient was noted. Age, weight, height, and lifestyle habits were recorded; and OPG, Ca(2+), intact parathyroid hormone (iPTH), 25-Hydroxyvitamin D (25OHD) and 1,25-Dihydroxyvitamin D (1,25(OH)(2)D), bone alkaline phosphatase, osteocalcin, and serum C-terminal cross-links telopeptide of type I collagen (ICTP) were determined. Dual-energy X-ray absorptiometry BMD at the lumbar spine, femoral neck, and hip was also measured. Serum OPG was higher in patients than in controls (91.7 +/- 25.8 vs. 77.2 +/- 26.3, P = 0.02). ICTP (a bone resorption marker) was 37% higher in patients (P = 0.007). Bone mass was lower in patients at the lumbar spine, femoral neck, and total hip. Lumbar spine Z-score showed a significant progressive decrease in controls, stage I-III patients, and stage IV patients. Logistic regression analysis showed a significant association between the disease and serum OPG levels, the odds ratio per standard deviation increase of this being 1.9 (95% confidence interval 1.1-3.8, P = 0.04) after adjusting for bone mass and ICTP serum levels, as well as for alcohol and smoking history. Adjustment for alcohol intake and tobacco use did not cancel out BMD differences between patients and controls. Patients with SCHNC show increased OPG serum levels, increased bone resorption, and decreased bone mass. The OPG rise appears to be unrelated to the BMD decrease, and the BMD decrease seems to be, at least in part, independent of smoking and drinking habits. No differences in either OPG or BMD were seen between patients with and without chemotherapy. Further studies are needed to clarify the mechanisms responsible for OPG and BMD changes in SCHNC.

[Calcaneous ultrasonography as measurement of osteoporosis prevalence in the general population in relation to the diagnostic criterion utilized. Data of the study GIUMO]

CONTEXT

In recent years, a large number of techniques have been developed to estimate the bone mineral density for the diagnosis of osteoporosis. However, diagnostic criteria established by WHO are invariably applied for the interpretation of dual radiological densitometry (DEXA), which could not be correct in the case of the interpretation of ultrasound.

METHOD

We studied 2,589 randomly chosen people of both sexes, 1,138 males and 1,451 women from 10 to 99 years, in 11 spanish provinces. We carried out a measurement of the following calcaneous ultrasound parameters with the Sahara and Hologic devices: speed of the sound (SOS), coefficient of attenuation of wide band (BUA), index of consistency (QUI) and estimated bone mineral density (est. BMD). The prevalence of osteopenia and osteoporosis was calculated by applying the WHO criteria (osteopenia Tscore < or = 1 and osteoporosis Tscore < or = 2.5) and the prevalence of osteoporosis by applying a Tscore 1.8 as threshold.

RESULTS

According to the WHO criteria, osteoporosis (Tscore < or = 2.5) is seen in 1.5 % males and 5.9 % females from 51 to 70 years, and in 2.6% males and 22.1% females over 70 years. Using a Tscore 1.8 as threshold, osteoporosis prevalence increases to 8.2% males and 21.9% females from 51 to 70 years, and to 8.4% males and 40.9% females over 70 years.

CONCLUSION

Osteoporosis prevalence in spanish people of both sexes differs notably when applying the cut off point in a Tscore of 2.5, as WHO recommends, or in a Tscore of 1.8 as is suggested by other authors. Consensus is necessary to establish the appropriate cut off point or threshold for the diagnosis of osteoporosis with quantitative ultrasonography of calcaneum.

[Inhibition of the proteolytic activity of Helicobacter pylori by mouse immune serum]

The proteolytic activity (PA) of some microorganisms is an important pathogenic factor during tissue invasion. However, its role in Helicobacter pylori infection is not clear. Due to the importance of the immunological response to inhibit pathogenic factors of microorganisms, this study aims to establish an in vitro system to detect inhibitory antibodies to the PA of H. pylori in mouse serum. We obtained mouse sera from animals immunized by oral and intraperitoneal inoculations with the raw bacterial extract (BE) of H. pylori, in which we had previously detected PA. The degradation of azocasein subtract for BE was inhibited in 49.23% and 22.6% using 5 micrograms/ml of serum proteins (SP) from oral and intraperitoneal inoculation, respectively. However, when using more than 25 micrograms/ml of SP of immune serum, PA was inhibited in a similar way than with control serum. In conclusion we present a methodology for the detection of inhibitory antibodies to PA of H. pylori in the serum of the immunized mouse.

[Diagnosis of osteoporosis by lateral chest X-ray]

BACKGROUND

Lateral chest X-rays may be helpful in the early detection of osteoporotic patients. We studied the proportion of chest X-ray reports in which the radiologist highlighted the presence of vertebral osteoporotic signs, as well as the proportion of patients with such records who were further studied by their physicians in order to confirm the diagnosis of osteoporosis.

PATIENTS AND METHOD

We reviewed both lateral chest X-ray records of 3,500 consecutive patients and their medical records with the ultimate diagnosis.

RESULTS

Radiology reports referred to the presence of vertebral abnormalities suggestive of osteoporosis in only 20% of potentially expected cases. Final medical records registered a diagnosis of osteoporosis in only one third of positive radiological records (6.3% of expected cases with vertebral abnormalities). Only two thirds of patients diagnosed with vertebral osteoporosis by their physician were adequately treated (4% of positive lateral chest X-ray reports).

CONCLUSION

Osteoporosis is a disease overlooked by both radiologists and clinicians. Lateral chest X-ray is a helpful diagnostic tool for osteoporosis but its usefulness is often

[Treatment of osteoporosis with calcium and vitamin D. Systematic review]

BACKGROUND

Systematic review of the efficacy of calcium and vitamin D for the treatment of osteoporosis.

MATERIAL AND METHOD

Review of the database MEDLINE between 1996 and may 1998, by the key words: osteoporosis, calcium, vitamin D (and related terms) and randomized clinical trial. Review of the electronic versions of Best Evidence, The Cochrane Library, congress abstracts and references from two main textbooks. Ascending review of the literature. All the reviews were performed independently by two of the authors. Design parameters and main results of the primary publications of the identified trials were tabulated. Two independent observers carried out methodological scoring of the studies. Results were tabulated and a judgement made for the results.

RESULTS

Eleven studies on calcium, 8 of vitamin D and 12 about calcitriol and other hormone derivatives were included. Studies with calcium were mainly performed on non-clinical populations and in three anti-fracture efficacy was analyzed. Results were positive in population with low baseline intake and substantial supplementation. Trials on vitamin D were done in non-clinical and on institutionalized populations. Trials with calcitriol were developed mainly in osteoporotic fracture populations and reached poorer methodological validity scores. Heterogeneity of the studies precluded a meta-analysis of the different treatments. Studies on calcium showed clinical efficacy in a more consistent way. Inter-observer score was good (kappa = 0.81) and there were no significant correlations between sample size and effect in the different studies.

CONCLUSIONS

Calcium treatment is efficacious in populations with low intake receiving substantial supplementation. Vitamin D is efficacious associated with calcium mainly in deficient populations. Efficacy of calcitriol and other derivatives is more controversial.

[Femoral osteolytic lesions with soft tissue tumors and hypercalcemia as presentation form of a B-cell lymphoma]

Hypercalcemia associated with haematological neoplasms account for 15 to 20% of hipercalcemia in malignancy, and occurs usually in patients with multiple myeloma. However, its incidence in patients with linfoma is low, and it is observed usually in T-cell linfomas. Bone affectation is also uncommon in patients with non-Hodgkin linfoma. It usually is seen as a late manifestation of the disease, and its occurrence as the form of presentation is exceptional. We hereby report a patient with a B-cell non-Hodgkin linfoma presenting with hypercalcemia and femoral osteolytic lesions.

Endocarditis due to Acinetobacter lwoffi on native mitral valve

Endocarditis due to Acinetobacter is a rare pathology with high mortality, reported mainly in hospitalized patients with predisposing risk factors. This is the second case of endocarditis due to Acinetobacter reported in our country in the last 10 years.

[Normative data for the neuropsychological evaluation of intravenous drug users]

BACKGROUND

There are many recent epidemiological studies that find that intravenous drug users' (IDU's) performance in several measures of neuropsychological function are not the same than that of the general population, whether they are seropositive to HIV-1 infection or not. Consequently, it has been stated the need to establish appropriate norms for this population. The purpose of this study is to provide normative data on a battery of neuropsychological tests from a IDU group.

SUBJECTS AND METHODS

This report provide normative data from a group of 116 IDU, on a battery of neuropsychological tests stratified by age group (mean = 30.9; SD = 4.5), and educational level (mean = 8; SD = 2.4). Comparisons between the means of the different groups according to age and education, and also with respect to sex are made. The analysis includes estimation of partial correlations between neuropsychological test scores and age and education.

RESULTS

The analysis demonstrates that education is an important determinant of performance for most of these tests, while there are no differences in performance between the two age-groups. With respect to sex, females out-performed men on a measure of motor speed and coordination.

CONCLUSIONS

This report provides norms that may be of use as a reference for clinical evaluation and research in drug user populations. It also emphasizes the need to establish normative data controlling for variables like educational level, from a population with special characteristics such as IDU population.

[Fever of unknown origin as the clinical presentation of malignant peritoneal mesothelioma]

Malignant peritoneal mesothelioma is a rare disease. The most frequent initial symptoms are abdominal pain, anorexia, marked weight loss and ascites. Clinical presentation as fever of unknown origin is exceptional. We report three cases diagnosed over a period of twenty years, two cases as fever of unknown origin and the third as prolonged fever. Three patients died within two months after diagnosis and prolonged fever was the clinical manifestation at the onset of the disease. It is important to take malignant peritoneal mesothelioma in the differential diagnosis of fever unknown origin.

[Changes in bone mass in hepatic cirrhosis, chronic obstructive pulmonary disease, insulin-dependent diabetes, and primary hyperparathyroidism]

BACKGROUND

Liver cirrhosis, chronic obstructive pulmonary disease (COPD), insulin-dependent diabetes mellitus and primary hyperparathyroidism are frequent diseases which are considered as risk factors for the development of osteoporosis. However, review of the literature has shown that the studies published on the aforementioned are far from conclusive.

METHODS

By double energy X-ray absorptiometry the bone mineral density (BMD) of the lumbar spine and neck of the femur were determined in 29 patients with liver cirrhosis, 92 with chronic obstructive pulmonary disease (59 treated with corticoids), 81 with insulin-dependent diabetes mellitus and 30 primary hyperparathyroidism (7 operated).

RESULTS

Cirrhotic patients had a normal BMD in both localizations. In patients with COPD, without corticoids, a decrease of 6% was found in the spine and or 13.5% in the neck of the femur while in patients with COPD with corticoids the decrease was of 12% and 7% respectively. Diabetic patients had normal BMD in the spine and a decrease of 6% in the neck of the femur and in patients with hyperparathyroidism a decrease of 6% and normality were found, respectively.

CONCLUSIONS

The repercussion of cirrhosis, insulin-dependent diabetes, and primary hyperparathyroidism on bone mineral density is nul or slight. In patients with chronic obstructive pulmonary disease treated with corticoids decrease in density of the spine is approximately that of a standard deviation. In patients with the latter not treated with corticoids a similar decrease is found in the neck of the femur.

[Phosphocalcium metabolism disorders in patients with active pulmonary tuberculosis]

Several parameters of phosphocalcic metabolism were evaluated in 21 patients with active pulmonary tuberculosis. The serum levels of total calcium, ionic calcium, phosphorus, albumin, magnesium and alkaline phosphatase, and calciuria and calcium/creatinine ratio in 24-hour urine were normal and not change during therapy. The patients with tuberculosis showed a significant reduction in the 250HD concentrations (8.8 +/- 5.2 ng/ml vs 19.2 +/- 10.7 ng/ml; p = 0.002), 1.25(OH)2D (25 +/- 8 pg/ml vs 34 +/- 9 pg/ml; p = 0.002) and parathyroid hormone (intact molecule) (1.9 +/- 0.9 pmol/l vs 5.9 +/- 2.0 pmol/l; p = 0.0001). By contrast, the levels of calcitonin (65 +/- 30 pg/ml vs 36 +/- 17 pg/ml; p = 0.001) and tartrate-resistant acid phosphatase (17.3 +/- 2.3 U/l vs 11.8 +/- 1.8 U/l; p = 0.0001) were increased. There also was a mild increase of vitamin D carrier protein (532 +/- 109 mg/l vs 480 +/- 37 mg/l; p = 0.04). These data are consistent with a partial inhibition of parathyroid hormone, associated with vitamin D deficiency. The inhibition of the axis of parathyroid hormone--1.125(OH)2D resulting from calcium release from the bone is advanced as an explanation. This release might be due to the action on the bone of cytokines produced within the inflammatory process itself. The reduction in 250HD could presumably be related with the lower exposure to sun, which is common in sick persons.

[Bone turnover markers in tumor pathology with bone involvement]

We evaluated the serum osteocalcin and alkaline phosphatase levels and the urinary hydroxyproline excretion in patients with blastic, lithic or mixed metastases, humoral malignant hypercalcemia (HMH) and myeloma. In patients with metastasis of any type osteocalcin did not reach a significant increase although in blastic metastases an increase approaching signification was observed. However, the sensitivities of alkaline phosphatase or hydroxyproline were much higher. In HMH hydroxyproline increased to levels similar to those found in primary hyperparathyroidism. By contrast, although osteocalcin had a significant increase, its values were much lower than in parathyroid disease. The changes in alkaline phosphatase were nonevaluable. In myeloma none of the three markers changed. The major conclusion of the present study is that osteocalcin has little practical usefulness for the investigation of neoplastic patients.

[Response of vitamin D metabolites to calcium restriction in hypercalciuric renal lithiasis]

A group of patients with hypercalciuric renal lithiasis and a group of controls underwent dietary calcium restriction, reinforced by cellulose phosphate, during two weeks. Before and after that intervention, serum levels of 25 OH D, 1.25(OH)2D and PTH, and urinary excretion of cAMP and hydroxyproline were measured. Although the baseline 1.25(OH)2D level was higher in patients with stones, it did not increase with diet as it was the case with controls. Also, the urinary excretion of cAMP was increased in controls but not in patients. 25 OH D, PTH and hydroxyproline were not changed. We conclude that dietary calcium restriction in patients with hypercalciuric renal lithiasis does not appear to induce hormonal changes potentially damaging for the bone.

[Effect of active metabolites of vitamin D on manifestations of primary hyperparathyroidism]

We have evaluated the serum levels of 25-hydroxyvitamin D (25-OHD) and 1,25-dihydroxyvitamin D (1.25-OHD) in 33 patients with primary hyperparathyroidism and normal renal function, relating them with the clinical expression of the disease and other biochemical parameters. The level of 1.25-OHD of the patients was significantly higher than in healthy controls [51 +/- 18 vs 36 +/- 10 pg/ml (122 +/- 43 vs 86 +/- 24 pmol/l), p less than 0.001], although it was higher than the upper limit of the normal range in only 36% of patients. By contrast, the level of 25-OHD was diminished [11.0 +/- 6.3 ng/ml (27.5 +/- 15.7 nmol/l) in the patients and 19.9 +/- 10.5 ng/ml (49.7 +/- 26.2 nmol/l) in the controls, p less than 0.01]. A positive correlation was found between PTH and 1.25-OHD (r = 0.40, p less than 0.05) and a negative one between PTH and 25-OHD (r = -0.40, p less than 0.05). Calcemia was correlated with PTH (r = 0.77, less than p 0.001) but not with 1.25-OHD (partial r = 0.22). There was no correlation between vitamin D metabolites and calciuria, nor between the former and the biochemical indexes of bone remodelling. There were no significant biochemical differences between patients with renal calculi and those without them. It was concluded that PTH level appears as the major determinant factor of 1.25-OHD serum level. The serum level of vitamin D metabolites does not seem to clearly influence calcemia, calciuria, bone remodelling or the development of calculi.

[Tumoral hypocalcemia]

Hypocalcemia is a rare and not well understood paraneoplasic manifestation. We report the clinical case of a patient with hypocalcemia due to extensive osteoblastic metastasis. The corrected serum calcium levels for albumin was 7.2 mg/dl. Calciuria was less than 10 mg/24 h. Magnesium, phosphate and 25-hydroxyvitamin D levels were normal. PTH and 1,25-dihydroxyvitamin D levels were increased. The pathogenesis of this disorder is possibly related to the massive calcium flow toward metastatic areas, that can not be compensated for by the activity of the PTH-vitamin D axis.

Aortobronchial fistula: an uncommon cause of haemoptysis

A 16 year old patient who presented with haemoptysis as the main manifestation of the infection of an aortic patch graft is reported. The importance of being alert about the possibility of an aortobronchial fistula in patients with haemoptysis who have been previously subjected to cardiovascular surgery is emphasized.

Vertebral compression fractures and mineral metabolism in chronic obstructive lung disease

Chronic obstructive lung disease has been reported as a cause of osteoporosis, though whether this association is due to the disease itself or to corticosteroid treatment has not been elucidated. We studied 44 male patients with chronic obstructive lung disease (mean (SD) FEV1 39% (14%) of predicted normal) who were not having long term corticosteroids. No differences in a vertebral deformity score or in metacarpal index were found between them and a control group of similar age. Indices of bone formation (serum osteocalcin) and bone resorption (urinary hydroxyproline) were normal and parathyroid hormone and 1,25-dihydroxyvitamin D were also normal. Serum 25-hydroxyvitamin D was decreased, indicating depleted vitamin D. Calcitonin concentrations were higher in the patient than in the control group of the same age. There was no increase in the prevalence of osteoporosis in patients with chronic obstructive lung disease who had not received long term corticosteroid treatment. Increased concentrations of calcitonin may protect the skeleton from the detrimental effect of hypovitaminosis D.