Vertebral compression fractures and mineral metabolism in chronic obstructive lung disease

Vitamin D supplementation may be beneficial in improving the prognosis of patients with chronic obstructive pulmonary disease in the intensive care unit: a retrospective study

Background

Vitamin D is a crucial fat-soluble vitamin that has garnered significant attention due to its potential impact on respiratory health. It is noteworthy that many patients with chronic obstructive pulmonary disease (COPD) often experience deficiencies or insufficiencies of vitamin D. To address this issue, our retrospective study aimed to explore the potential association between serum 25-hydroxyvitamin D concentration and the prognoses of COPD patients in the Intensive Care Unit (ICU).

Methods

This study utilised data from the Medical Information Marketplace in Intensive Care IV (MIMIC-IV), a database of patients admitted to the Intensive Care Unit at Beth Israel Deaconess Medical Center (BIDMC) in the United States of America, with a focus on patients with a diagnosis of COPD. These patients were categorized into two groups: those who received vitamin D supplementation during their ICU stay and those who did not. We assessed in-hospital mortality and ICU mortality outcomes. Our analysis involved various analytical tools, including Kaplan-Meier survival curves, Cox proportional risk regression models, and subgroup analyses, to investigate the relationship between vitamin D supplementation and these outcomes. Additionally, we employed propensity-score matching (PSM) to enhance the reliability of our findings.

Results

The study included a total of 3,203 COPD patients, with 587 in the vitamin D group and 2,616 in the no-vitamin D group. The Kaplan-Meier survival curve demonstrated a significant difference in survival probability between the two groups. After adjusting for potential confounders using Cox regression models, the vitamin D group exhibited a substantially lower risk of in-hospital and ICU mortalities compared to the no-vitamin D group. The hazard ratios for in-hospital and ICU mortalities in the vitamin D group were 1.7 (95% CI: 1.3, 2.3) and 1.8 (95% CI: 1.2, 2.6), respectively. Propensity-score matching (PSM) estimation yielded consistent results. Furthermore, in the subgroup analysis, female patients who received vitamin D supplementation showed a reduced risk of in-hospital mortality.

Conclusion

The study suggests that vitamin D supplementation may be linked to a reduction in in-hospital and ICU mortalities among COPD patients in the ICU. Of particular note is the potential benefit observed in terms of in-hospital mortality, especially for female patients.

The Effect of Age on Fracture Healing Time in Metacarpal Fractures

Background: Older patients are treated for fracture with increasing frequency. Although studies on animals suggest that older mice and rats heal fractures more slowly, the clinical implications remain unclear. A better understanding of differences in healing with age can help customize fracture treatment. Our purpose was to retrospectively evaluate metacarpal fractures for healing time looking specifically at age-related differences. Methods: A retrospective review of patients treated for metacarpal fractures was conducted. Patients with incomplete charts or inadequate follow-up were excluded. One hundred ninety-eight charts were analyzed. Demographic and other patient factors were documented. Fracture characteristics and treatment type were documented. Fracture healing was determined clinically. Plain radiographs and examination were used in decision making. Results: Age was not associated with fracture healing time as a continuous variable (P = .09). Patients above 75 years were not associated with increased healing time (P = .58). Fracture characteristics were related to healing time: minimally displaced and comminuted fractures healed faster than oblique fractures, spiral fractures, or transverse fractures (P = .048). Patients undergoing surgery healed faster than those without surgery (P = .046). Renal failure negatively affected fracture healing time (P = .03). Diabetes, hypothyroidism, and gender were not associated with healing time. Complications were not associated with age or other patient or fracture-related factors. Conclusions: Age does not affect clinical fracture healing time in adult. Therefore, older patients do not require disparate treatment. Other fracture-related factors and considerations such as functional demand and support systems might influence treatment decisions in fracture care.

Spinal Compression Fracture Management: A Review of Current Treatment Strategies and Possible Future Avenues

STUDY DESIGN

Narrative review.

OBJECTIVE

Despite the numerous treatment options for vertebral compression fractures, a consensus opinion for the management of patients with these factures has not been established. This review is meant to provide an up-to-date overview of the most common treatment strategies for compression fractures and to suggest possible routes for the development of clearer treatment guidelines.

METHODS

A comprehensive database search of PubMed was performed. All results from the past 30 years were obtained and evaluated based on title and abstract. The full length of relevant studies was analyzed for level of evidence, and the strongest studies were used in this review.

RESULTS

The major treatment strategies for patients with compression fractures are conservative pain management and vertebral augmentation. Despite potential adverse effects, medical management, including nonsteroidal anti-inflammatory drugs, calcitonin, teriparatide, and bisphosphonates, remains the first-line therapy for patients. Evidence suggests that vertebral augmentation, especially some of the newer procedures, have the potential to dramatically reduce pain and improve quality of life. At this time, balloon-assisted kyphoplasty is the procedure with the most evidence of support.

CONCLUSIONS

Based on current literature, it is evident that there is a lack of standard of care for patients with vertebral compression fractures, which is either due to lack of evidence that a procedure is successful or due to serious adverse effects encountered with prolonged treatment. For a consensus to be reached, prospective clinical trials need to be formulated with potential new biomarkers to assess efficacy of treatment strategies.

Relationship between pulmonary function and bone mineral density in the Korean National Health and Nutrition Examination Survey

BACKGROUND/AIMS

Osteoporosis is common in chronic obstructive pulmonary disease (COPD) patients. The relationship between osteoporosis and COPD has been primarily reported in patients with moderate to severe COPD, but there is no report in the general population. The aim of this study is to investigate the relationship between bone mineral density (BMD) and lung function in the general Korean population.

METHODS

This study was based on data acquired from the Fourth and Fifth Korea National Health and Nutrition Examination Surveys (KNHANES IV and V), conducted from 2008 to 2010. The study population included 4,501 subjects (aged ≥ 50 years) who underwent both spirometry and BMD. The study populations were divided into two groups by sex to correct for the effects of gender on BMD. All female participants were postmenopausal women.

RESULTS

The BMD values of the femur neck, total femur, and L-spine tended to decrease with degree of airflow limitation in both genders. To correct confounding factors, data were analyzed and adjusted for age, body mass index, fat free mass index, body fat percentage, smoking amount, parathyroid hormone levels, daily calcium and phosphorus intake, and alkaline phosphatase (ALP) levels. While the BMD of the femur neck, total femur, and L-spine was reduced significantly as age and ALP increased, the correlation between airway obstruction and BMD of all regions disappeared in both genders.

CONCLUSIONS

In the general population aged 50 years and older, diminution of BMD is not associated with airway obstruction. Further investigation along other factors is needed to determine the possible role of pulmonary function and BMD.

Relationship between vitamin D and lung function, physical performance and balance on patients with stage I-III chronic obstructive pulmonary disease

Summary Objectives: vitamin D is important for muscle function and it affects different aspects of muscle metabolism. This study aim to determine whether serum 25(OH) D levels are related to lung functions, physical performance and balance in patients with chronic obstructive pulmonary disease (COPD). Methods: in 90 patients with COPD and 57 healthy controls lung function tests, physical performance tests (time up and go, gait velocity test, sit-to-stand test, isometric strength, isokinetic strength), static (functional reach test) and dynamic (time up and go) balance tests and the association of 25(OH)D levels with lung functions, physical performance and balance were evaluated. Results: the COPD patients had significantly more deficit in physical function and balance parameters, and in dynamic balance test (p<0.005). Isokinetic knee muscle strength (flexor and extensor) in COPD patients was significantly lower than in the controls (p<0.05); FEV1 (p=0.008), FVC (p=0.02), FEV1/FVC (p=0.04), TLC (p=0.01) were lower in COPD patients with vitamin D deficiency [25(OH) D less than 15ng/mL] than in COPD patients without vitamin D deficiency. Hand grip test (p=0.000) and isokinetic knee muscle strength (flexor and extensor) (p<0.05) were also lower in COPD patients with vitamin D deficiency. Vitamin D deficiency was more pronounced in patients with stage III COPD (p<0.05). Conclusion: patients with COPD had worst physical functioning, poor balance and less muscle strength. Severe disturbed lung and peripheral muscle functions are more pronounced in COPD patients with vitamin D deficiency.

Avaliação da prevalência de osteoporose e fraturas vertebrais em pacientes portadores de doença pulmonar obstrutiva crônica

INTRODUÇÃO: A osteoporose é uma doença progressiva que contribui para o surgimento de fraturas vertebrais. OBJETIVOS: Avaliar a prevalência da osteoporose, fraturas vertebrais e intensidade da dor nas regiões da coluna vertebral em pacientes com DPOC moderada e grave, além de verificar se há relação entre tais variáveis e a gravidade da obstrução pulmonar. MATERIAIS E MÉTODOS: Foram avaliados 34 indivíduos portadores de DPOC (GDPOC) e 33 indivíduos saudáveis (GC), por meio da densitometria óssea e radiografias da coluna torácica e lombar. RESULTADOS: Não houve diferenças significativas intergrupos nos dados antropométricos. O GDPOC apresentou valores menores nas variáveis espirométricas, na densidade mineral óssea (DMO) e no escore-T, quando comparado com o GC (p < 0,05; Teste t Student); além disso, não se observou correlação entre VEF1 e DMO e escore-T (Correlação de Pearson, p > 0,05). Verificou-se uma alta prevalência de osteoporose, sendo que 20 indivíduos (59%) com obstrução moderada apresentaram na coluna lombar, l (3%) no colo do fêmur e l (3%) no trocânter; 4 (12%) com obstrução pulmonar grave na coluna lombar, l (3%) no colo do fêmur e l (3%) no trocânter. Vinte indivíduos (59%) do GDPOC com osteoporose apresentaram fraturas de graus I e II, 4 (12%) grau III (k = 0,90; IC: 95%) e 3 indivíduos do GDPOC relataram presença de dor com intensidade "leve" na região toracolombar, enquanto 21 apresentaram fraturas vertebrais osteoporóticas assintomáticas. CONCLUSÃO Concluímos que os indivíduos com DPOC de moderada a grave apresentaram, além do comprometimento pulmonar, diminuição da DMO e fraturas vertebrais osteoporóticas, o que indica a necessidade de se adotar medidas de prevenção da osteoporose nesses pacientes.

Vitamin d status in patients with chronic obstructive pulmonary disease who participate in pulmonary rehabilitation

PURPOSE

Vitamin D deficiency is common in patients with chronic obstructive pulmonary disease; however, no study has evaluated the influence of vitamin D status on effects of pulmonary rehabilitation (PR).

METHODS

We studied 311 patients, who participated in a 7-week outpatient PR. Vitamin D status was assessed at entry and examined for association with patient characteristics, dropout from PR, and effect on endurance shuttle walk time.

RESULTS

Vitamin D level 25 nM was seen in 61 (19.6%) of the patients. They were significantly younger, were more frequently on long-term oxygen therapy, had higher body mass index and fat-free mass index, had worse quality of life score, tended to have lower percent predicted value for forced expiratory volume in the first second of expiration, and more frequently were current smokers. They had a 3-time higher risk of dropout from the PR program (P = .003) compared with patients with normal vitamin D status and a poorer improvement in endurance shuttle walk time (P = .03).

DISCUSSION

In conclusion, vitamin D deficiency was significantly associated with higher dropout rates from PR, and there was a tendency toward a poorer improvement in endurance shuttle walk time.

Low bone mineral density in men with chronic obstructive pulmonary disease

Background

Osteoporosis is common in patients with COPD but the likely multi-factorial causes contributing to this condition (e.g. sex, age, smoking, therapy) mask the potential contribution from elements related to COPD. In order to study osteoporosis and bone mineral density (BMD) related to COPD, we studied a well-defined group of patients and controls.

Methods

BMD, forced expiratory volume in one second (FEV₁), circulating bone biomarkers and biochemistry were determined in 30 clinically stable male ex-smokers with confirmed COPD and 15 age matched "ex-smoker" male controls. None of the patients were on inhaled corticosteroids or received more than one short course of steroids.

Results

Mean (SD) FEV₁% predicted of patients was 64(6)%, the majority having Global Initiative for Chronic Obstructive Lung Disease (GOLD) II airflow obstruction. There were 5/30 patients and 1/15 controls who were osteoporotic, while a further 17 patients and 5 controls were osteopenic. The BMD at the hip was lower in patients than controls, but not at the lumbar spine. Mean values of procollagen type 1 amino-terminal propeptide and osteocalcin, both markers of bone formation, and Type 1 collagen β C-telopeptide, a marker of bone resorption, were similar between patients and controls. However, all bone biomarkers were inversely related to hip BMD in patients (r = -0.51, r = -0.67, r = -0.57, p < 0.05) but did not relate to lumbar spine BMD. 25-OH Vitamin D was lower in patients.

Conclusions

Men with COPD had a greater prevalence of osteoporosis and osteopenia than age matched male controls, with a marked difference in BMD at the hip. Bone biomarkers suggest increased bone turnover.

An estimate of the global reduction in mortality rates through doubling vitamin D levels

BACKGROUND/OBJECTIVES

The goal of this work is to estimate the reduction in mortality rates for six geopolitical regions of the world under the assumption that serum 25-hydroxyvitamin D (25(OH)D) levels increase from 54 to 110 nmol/l.

SUBJECTS/METHODS

This study is based on interpretation of the journal literature relating to the effects of solar ultraviolet-B (UVB) and vitamin D in reducing the risk of disease and estimates of the serum 25(OH)D level-disease risk relations for cancer, cardiovascular disease (CVD) and respiratory infections. The vitamin D-sensitive diseases that account for more than half of global mortality rates are CVD, cancer, respiratory infections, respiratory diseases, tuberculosis and diabetes mellitus. Additional vitamin D-sensitive diseases and conditions that account for 2 to 3% of global mortality rates are Alzheimer's disease, falls, meningitis, Parkinson's disease, maternal sepsis, maternal hypertension (pre-eclampsia) and multiple sclerosis. Increasing serum 25(OH)D levels from 54 to 110 nmol/l would reduce the vitamin D-sensitive disease mortality rate by an estimated 20%.

RESULTS

The reduction in all-cause mortality rates range from 7.6% for African females to 17.3% for European females. Reductions for males average 0.6% lower than for females. The estimated increase in life expectancy is 2 years for all six regions.

CONCLUSIONS

Increasing serum 25(OH)D levels is the most cost-effective way to reduce global mortality rates, as the cost of vitamin D is very low and there are few adverse effects from oral intake and/or frequent moderate UVB irradiance with sufficient body surface area exposed.

Vitamin D and responses to inhaled fluticasone in severe chronic obstructive pulmonary disease

Background

Patients with chronic obstructive pulmonary disease (COPD) demonstrate variable responses to inhaled corticosteroids (ICS). The factors contributing to this variability are not well understood. Data from patients with asthma have suggested that low 25-hydroxyvitamin D [25(OH)D] levels contribute to a lack of ICS response in asthma. The objective of this study was to determine whether serum levels of 25(OH)D were related to ICS responses in patients with COPD.

Methods

A total of 60 exsmokers with severe COPD (mean forced expiratory volume in one second [FEV₁] 1.07 L, 36% of predicted) spent 4 weeks free of any ICS, followed by 4 weeks of ICS use (fluticasone propionate 500 μg twice daily). Spirometry was performed prior to and after 4 weeks of ICS use. Blood 25(OH)D levels were measured prior to ICS use and examined for relationships to changes in FEV₁ following the 4 weeks of ICS use.

Results

The mean 25(OH)D level was 23.3 ± 9.3 ng/mL. There was a high prevalence of vitamin D insufficiency (35%) and deficiency (40%). There was no relationship between baseline 25(OH)D and changes in FEV₁ following 4 weeks of ICS.

Conclusion

Baseline 25(OH)D does not contribute to the variation in short-term FEV₁ responses to ICS in patients with severe COPD.

A systematic review of the role of vitamin insufficiencies and supplementation in COPD

BACKGROUND

Pulmonary inflammation, oxidants-antioxidants imbalance, as well as innate and adaptive immunity have been proposed as playing a key role in the development of COPD. The role of vitamins, as assessed either by food frequency questionnaires or measured in serum levels, have been reported to improve pulmonary function, reduce exacerbations and improve symptoms. Vitamin supplements have therefore been proposed to be a potentially useful additive to COPD therapy.

METHODS

A systematic literature review was performed on the association of vitamins and COPD. The role of vitamin supplements in COPD was then evaluated.

CONCLUSIONS

The results of this review showed that various vitamins (vitamin C, D, E, A, beta and alpha carotene) are associated with improvement in features of COPD such as symptoms, exacerbations and pulmonary function. High vitamin intake would probably reduce the annual decline of FEV1. There were no studies that showed benefit from vitamin supplementation in improved symptoms, decreased hospitalization or pulmonary function.

Vitamin D deficiency and chronic lung disease

Vitamin D deficiency is increasingly being recognized as a prevalent problem in the general population. Patients with chronic lung diseases such as asthma, cystic fibrosis, chronic obstructive lung disease and interstitial pneumonia appear to be at increased risk for vitamin D deficiency for reasons that are not clear. Several studies indicate that vitamin D possesses a range of anti-inflammatory properties and may be involved in processes other than the previously believed functions of calcium and phosphate homeostasis. Various cytokines, cellular elements, oxidative stress and protease/antiprotease levels appear to affect lung fibroproliferation, remodelling and function, which may be influenced by vitamin D levels. Chronic lung diseases such as asthma and chronic obstructive lung disease have also been linked to vitamin D on a genetic basis. This immune and genetic influence of vitamin D may influence the pathogenesis of chronic lung diseases. A recent observational study notes a significant association between vitamin D deficiency and decreased pulmonary function tests in a large ambulatory population. The present review will examine the current literature regarding vitamin D deficiency, its prevalence in patients with chronic lung disease, vitamin D anti-inflammatory properties and the role of vitamin D in pulmonary function.

Vitamin D status and longitudinal lung function decline in the Lung Health Study

Low blood vitamin D levels have been postulated to be a risk factor for worse lung function, based largely on cross-sectional data. We sought to use longitudinal data to test the hypothesis that baseline plasma 25-hydroxyvitamin D (25(OH)D) is lower in subjects with more rapid lung function decline, compared to those with slow lung function decline. We conducted a nested, matched case-control study in the Lung Health Study 3 cohort. Cases and controls were continuous smokers with rapid and slow lung function decline, respectively, over ~6 yrs of follow-up. We compared baseline 25(OH)D levels between cases and controls, matching date of phlebotomy and clinical centre. Among 196 subjects, despite rapid and slow decliners experiencing strikingly and significantly different rates of decline of forced expiratory volume in 1 s (-152 versus -0.3 mL·yr⁻¹; p < 0.001), there was no significant difference in baseline 25(OH)D levels (25.0 versus 25.9 ng·mL⁻¹; p = 0.54). There was a high prevalence of vitamin D insufficiency (35%) and deficiency (31%); only 4% had a normal 25(OH)D level in the winter. Although vitamin D insufficiency and deficiency are common among continuous smokers with established mild-to-moderate chronic obstructive pulmonary disease, baseline 25(OH)D levels are not predictive of subsequent lung function decline.

Chronic obstructive pulmonary disease is associated with osteoporosis and low levels of vitamin D

We did a cross-sectional analysis of chronic pulmonary obstructive disease (COPD) patients without chronic use of systemic glucocorticoids (CUG). Osteoporosis was found in 51% and bone mineral density (BMD) was correlated with severity of disease. Low levels of vitamin D were found in 94%. All COPD patients may benefit from vitamin D supplementation and screening for low BMD.

INTRODUCTION

Patients with chronic pulmonary obstructive disease have low bone mineral density, caused by chronic use of systemic glucocorticoids and hypovitaminosis D. However, patients without CUG may also have low BMD.

METHODS

We performed a cross-sectional analysis in 49 patients (21 men, 28 postmenopausal women), with COPD without CUG, from Brazil (25 degrees 25' S). Several markers of bone metabolism were measured, plus BMD. Osteoporosis risk factors and history of fractures were investigated. Respiratory function was assessed by venous gasometry, spirometry, and oximetry. BMD results were compared to those of 40 healthy non-smokers controls.

RESULTS

COPD patients had lower BMD at all sites (p < 0.01). Osteoporosis was observed in 51%. BMD independently correlated with stage of disease (lumbar spine, R = 0.38, p = 0.01; total femur, R = 0.36, p = 0.01; femoral neck, R = 0.40, p < 0.01). Ninety-four percent had low levels of vitamin D (<30 ng/mL) and 67% had secondary hyperparathyroidism. Vitamin D was correlated with oxygen saturation (R = 0.36, p = 0.01), with lower levels in those with saturation <88% (p = 0.01).

CONCLUSION

Patients with COPD without CUG have increased risk for osteoporosis. Such patients have hypovitaminosis D, which is correlated with the severity of disease. Screening for low BMD and vitamin D supplementation may be warranted to all COPD patients.

Targeted treatment in COPD: a multi-system approach for a multi-system disease

Chronic obstructive pulmonary disease is a varied condition when examined from a number of different perspectives including factors which influence disease development, pathological process and clinical features. There may be a complex interaction between the degree by which each of these processes influences the development of COPD and the subsequent clinical phenotype with which the patient presents. The varied host response and subsequent clinical phenotype has generated much interest in recent years. It is possible that failure of treatment to impact on mortality and reverse the disease process is because of the heterogeneous nature of the condition. Identification and targeted treatment of clinical and pathological phenotypes within the broad spectrum of COPD may therefore improve outcome. This article will review previous work which has attempted to phenotype COPD and identify if specific treatment for these phenotypes has been shown to be of benefit. It will examine the work on pathological processes and clinical manifestations, both pulmonary and systemic, and will focus on pharmacological therapies.

Vertebral fractures in patients with chronic obstructive pulmonary disease: the EOLO Study

SUMMARY

This study aimed to evaluate the prevalence of vertebral fractures to investigate the determinants of vertebral fracture risk in patients with COPD. The risk of vertebral fractures is strictly related to the severity of the disease. The use of glucocorticoids and the presence of low values of quantitative ultrasound (QUS) may represent additional risk factors.

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) appears to be associated with osteoporosis. Our study aimed to evaluate the prevalence of vertebral fractures and to investigate the main determinants of vertebral fracture risk in patients with COPD.

METHODS

In 3,030 ambulatory COPD patients (1,778 men and 1,262 women) aged 50 years or over, we evaluated: COPD severity, presence of vertebral fractures on lateral chest X-ray and bone status by using a quantitative ultrasound device.

RESULTS

In men there was a strong association between COPD severity and fractures (p < 0.001), conversely in women the association between COPD severity and fractures was at limit (p = 0.049). In men, but not in women, glucocorticoid treatment was significantly associated with vertebral fractures. The patients with high or moderate risk of osteoporosis presented an increased risk of vertebral fracture (OR 2.71; 95% CI 2.04-3.60 and OR 1.54; 95% CI 1.26-1.88, respectively). Logistic regression analysis showed that COPD severity and glucocorticoid treatment, both inhaled and oral, were associated with increased risk of vertebral fractures.

CONCLUSION

In COPD patients the risk of vertebral fractures is strictly related to the severity of the disease. The use of glucocorticoids and reduced QUS at calcaneous may represent additional risk factors.

Falls in patients with chronic obstructive pulmonary disease: a call for further research

Chronic obstructive pulmonary disease (COPD) is a respiratory disease that results in airflow limitation and respiratory distress. The effects of COPD, however, are not exclusively limited to respiratory function and people with COPD face many non-respiratory manifestations that affect both function and mobility. Deficits in function and mobility have been associated with an increased risk for falling in older adults. The purpose of this study was to provide a theoretical framework to identify risks factors for falls in people with COPD. We have analyzed the literature to identify possible relationships between pathophysiological changes observed in COPD and common risk factors for falls. Well-established fall risk factors in people with COPD include lower limb muscle weakness and impaired activities of daily living. Other intrinsic risk factors such as gait and balance deficits, nutritional depletion, malnutrition, depression, cognitive impairments and medications are possible risk factors that need to be confirmed with more studies. There is no evidence that visual deficits are common in COPD. The role that precipitating factors such as syncope and postural hypotension may have on fall risk is unclear. Exacerbations and dyspnea do not have a precipitating effect on fall risk but they contribute to the progressive physical deterioration that may theoretically increase the risk for falls. While these results suggest that people with COPD might have an increased susceptibility to fall compared to their healthy peers, further research is needed to determine the prevalence of falls and specific risk factors for falls in people living with COPD.

Low bone mineral density is related to severity of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) appears to be associated with low bone mineral density (BMD). BMD loss can be accelerated by a number of factors associated with COPD, but it is not known whether COPD itself has a direct effect. Our aim was to investigate in a cross-sectional study whether COPD patients have lower BMD than healthy individuals, and whether the severity of the disease affects BMD. Eighty-eight COPD patients attending a rehabilitation program were classified into stages II, III and IV using GOLD criteria. BMD was measured by dual X-ray absorptiometry in lumbar spine (L2-4), femoral neck (FN) and total body (TB). Values were converted to Z-scores (adjusted for age and sex). Associations between Z-scores and steroid use, body mass index, pack-years and six-min walking distance were analyzed. The Z-scores (mean and (CI)) for all patients were for L2-4: -0.6 (-0.9, -0.3), FN: -0.8 (-1.0, -0.5) and TB: -0.5 (-0.8, -0.2). All scores were significantly different from those of a control population (p<0.001). For all three variables (ZL2-4, ZFN, ZTB) there were significant differences between the stages. The difference for ZL2-4 was still significant after adjustment for risk factors. We conclude that BMD is low in COPD patients and decreases with increasing severity of the disease. Low BMD may to some extent be a disease-specific effect.

Vertebral fracture assessment: the 2005 ISCD Official Positions

Vertebral Fracture Assessment (VFA) is a low radiation method for imaging the thoraco-lumbar spine using bone densitometers. VFA can easily be performed at the time of bone mineral density (BMD) measurement, allowing integration of BMD and vertebral fracture information into clinical patient care. As VFA is a relatively new procedure, it has received limited study and heretofore has not had widespread clinical application. Consequently, the International Society for Clinical Densitometry (ISCD) considered the following VFA issues at the 2005 Position Development Conference: (1) indications for VFA; (2) methodology for the diagnosis of vertebral fractures using VFA; and (3) indications for additional imaging after VFA. The ISCD Official Positions with respect to the above issues, as well as the rationale and evidence used to derive these positions, are presented here.

Bone Mineral Density Improvement After Lung Volume Reduction Surgery for Severe Emphysema

BACKGROUND

In patients with severe emphysema, bone mineral density (BMD) is reduced and the risk of osteoporosis is increased.

STUDY OBJECTIVES

To identify the impact of lung volume reduction surgery on BMD.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENTS AND INTERVENTIONS

Forty emphysematous patients, all receiving oral steroid therapy, underwent bilateral lung volume reduction surgery. Thirty similar patients, who refused the operation, followed a standard respiratory rehabilitation program.

MEASUREMENTS

All subjects were evaluated pretreatment and 12 months posttreatment for respiratory function, nutritional status, and bone-related biochemical parameters. BMD was assessed by dual-energy radiograph absorptiometry.

RESULTS

After surgery, we observed significant improvements in respiratory function (FEV1, + 18.8% [p < 0.01]; residual volume [RV], -29.6% [p < 0.001]; diffusing capacity of the lung for carbon monoxide [Dlco], + 21.6% [p < 0.01]) nutritional parameters (fat-free mass, + 6.0% [p < 0.01]), levels of bone-related hormones (free-testosterone, + 20.5% [p < 0.01]; parathormone, -11.2% [p < 0.01]), bone turnover markers (osteocalcin, -12.7% [p < 0.05]; bone-alkaline-phosphatase, -14.0% [p < 0.05]; beta-crosslaps, -33.6% [p < 0.001]), BMD (lumbar, + 8.8% [p < 0.01]; femoral, + 5.5% [p < 0.01]), and T-score (lumbar, + 21.0% [p < 0.01]; femoral, + 12.4% [p < 0.01]) with reduction in osteoporosis rate (50 to 25%). Nineteen patients who had undergone surgery were able to discontinue treatment with oral steroids. These subjects showed a more significant improvement in BMD (lumbar, + 9.6%; femoral, + 6.8%; p < 0.001) and T-score (lumbar, + 27.3%; femoral, + 14.3%; p < 0.001). The remaining 21 patients who had undergone surgery experienced significant improvement compared to respiratory rehabilitation subjects despite continued therapy with oral steroids (BMD: lumbar, + 4.5% vs -0.7%, respectively [p < 0.01]; femoral, + 2.7% vs -1.1%, respectively [p < 0.05]; T-score: lumbar, + 14 vs -2.1, respectively [p < 0.01]; femoral, + 7.4 vs -2.7, respectively [p < 0.01]). The increase in lumbar BMD was correlated with the surgical reduction of RV (p = 0.02) and with the increase in Dlco (p = 0.01) and fat-free mass (p = 0.01).

CONCLUSIONS

Lung volume reduction surgery significantly improves BMD compared to respiratory rehabilitation therapy, even in patients requiring oral steroids. The increase in BMD correlates with RV, Dlco, and fat-free mass, suggesting that the restoration of respiratory dynamics, gas exchange, and nutritional status induces improvement in bone metabolism and mineral content.

Association between respiratory function and osteoporosis in pre- and postmenopausal women

OBJECTIVE

To investigate the relationships between respiratory function and osteoporosis, 132 premenopausal and 98 postmenopausal women were evaluated.

METHODS

Bone mineral density (BMD) was measured with dual-energy X-ray absorptiometry. Pulmonary function and anthropometric parameters were measured using a spirometer and a body composition analyzer.

RESULTS

Lumbar spine and proximal femur BMDs in postmenopausal women with forced expiratory volume in 1s (FEV1) > or = 92.0% averaged 0.83 +/- 0.12 g/cm2 and 0.67 +/- 0.11 g/cm2, which were significantly above the values (0.76 +/- 0.14 g/cm2 and 0.61 +/- 0.12 g/cm2, P < 0.05) in those with FEV1 <92.0%. The prevalences of osteoporosis at lumbar spine and proximal femur were 59.2 and 46.9% in the postmenopausal women with peak expiratory flow rate (PEFR) <5.12 l/s, significantly higher than those of osteoporosis at the corresponding sites in the women with > or = 5.12 l/s (36.7 and 20.4%, P < 0.05). Lumbar spine and proximal femur BMDs were positively correlated with FEV1 (r = 0.28, P < 0.05; r = 0.31, P < 0.05) and PEFR (r = 0.35, P < 0.05; r = 0.23, P < 0.05) in postmenopausal women; however, no significant correlations were observed in premenopausal women.

CONCLUSION

Pulmonary function seems to be more closely associated with BMD in postmenopausal women than in premenopausal women. Poor respiratory function may be an indicator of postmenopausal women at increased risk of osteoporosis.

Vitamin D deficiency, bone mineral density and weight in patients with advanced pulmonary disease

OBJECTIVE

To study the influence of underweight, body composition and vitamin D deficiency on bone mineral density in patients with advanced pulmonary disease.

DESIGN

Cross-sectional study with time span for inclusion set at 5 years.

SETTING

The clinical work and biochemical analyses were carried out at Rikshospitalet University Hospital, Norway. Analyses for vitamin D metabolites and bone markers were carried out at Aker University Hospital, and bone measurements at Clinic of Osteoporosis.

SUBJECTS

Seventy-one candidates for lung transplantation (63% chronic obstructive pulmonary disease, 42 underweight and 29 normal weight) were included.

MAIN OUTCOME MEASURES

Body composition, bone mineral density at lumbar spine and femur neck, serum concentration of calcidiol and vitamin D intake.

RESULTS

Subnormal calcidiol levels were present in 52% of the underweight patients and 69% of the normal-weight patients. The resulting models of linear regression showed that for the lumbar spine T scores model, the total variation of 16.7% was explained by group (underweight/normal weight), sex and age. For the femur neck T scores model, the total variation of 20.4% was explained by the interaction of underweight and vitamin D deficiency (with borderline significance) and by arm muscle circumference percentage of standard. In patients with normal calcidiol levels, the median intake of vitamin D was 17 microg in the underweight patients and 11 microg in the normal-weight patients.

CONCLUSIONS

Vitamin D deficiency was common in both underweight and normal-weight patients, but only in the underweight patients, an association between vitamin D deficiency and reduced femur neck T scores was indicated.

Prevalence of vertebral fractures among patients with chronic obstructive pulmonary disease in Canada

PURPOSE

Patients with chronic obstructive pulmonary disease (COPD) may be at higher risk for osteoporosis. The primary objective of this case-control study was to determine the prevalence of vertebral fractures among patients with COPD admitted to acute care compared with a gender- and age-matched control group.

SUBJECTS AND METHODS

Subjects were identified by chart reviews from an acute care hospital in Hamilton, Ontario, in 1999, including patients who were over 50 years old. In total, 127 patients with ICD-9 codes specifying COPD were randomly selected and compared with 127 gender- and age-matched controls. Chest radiographs were interpreted by two radiologists who defined and graded vertebral fractures using Genant's method. Medications taken, or prescribed at discharge, were recorded from charts.

RESULTS

The overall prevalence of at least one vertebral fracture was found to be 34/127 (26.8%) in the COPD patients compared with 30/127 (23.6%) in the controls ( p=0.556). A significantly greater proportion of COPD patients had at least one severe vertebral fracture (OR=3.75, 95% CI 1.24 to 11.3). Review of hospital chest X-ray reports indicated that only 12 of 64 (18.8%) patients with vertebral fractures identified by the study radiologists actually had a vertebral fracture noted in the report. The proportion of COPD patients with vertebral fractures who were discharged on osteoporosis therapy was 5/27 (18.5%). There was a suggestion of lower lung function, as measured by forced vital capacity (FVC%), in patients with severe vertebral fractures ( p=0.067).

CONCLUSIONS

These data indicate that: (1) There is an increased proportion of COPD patients with severe vertebral fracture, and (2) Documentation and treatment of osteoporosis in acute care COPD patients is low. Therefore, there is a need to target this high-risk group for osteoporosis screening and potential clinical management.

Inhaled corticosteroids effects on bone in asthmatic and COPD patients: a quantitative systematic review

Deleterious effect of oral corticosteroids on bone has been well documented, whereas this remains debated for inhaled ones (ICS). Our objectives were to analyze the effects of ICS on bone mineral density, fracture risk and bone markers. We performed an exhaustive systematic research of all controlled trials potentially containing pertinent data, peer-reviewed by a dedicated WHO expert group, and comprehensive meta-analyses of the data. Inclusion criteria were ICS, and BMD/markers/fractures in asthma/chronic obstructive pulmonary diseases (COPD) and healthy patients. Analyses were performed in a conservative fashion using professional dedicated softwares and stratified by outcome, study design and ICS type. Results were expressed as standardized mean difference/effect size (ES), relative risk (RR) or odds ratio (OR), depending on study design and outcome units. Publication bias was investigated. Twenty-three trials were reviewed; 11 papers fit the inclusion criteria and were assessed for the main analysis. Quality scores for the randomized controlled trials (RCTs) were 80%, 71% for the prospective cohort studies, and 78% for the retrospective cohort and cross-sectional studies. We globally assessed ICS effects on BMD and found deleterious effects: ES=0.61 ( p=0.001) for healthy subjects, and ES=0.27 ( p<0.001) for asthma/COPD patients. For these patients, this effect was 0.21 ( p<0.01) at the lumbar spine, and 0.26 ( p<0.001) at the hip or femoral neck. A single study evaluated the impact of ICS on hip fracture and reported an increased OR of 1.6 (1.24; 2.03). Lumbar fracture rate differences did not reach the level of statistical significance: 1.87 (0.5; 6.94). Osteocalcin and PICP were decreased and ICTP, pyridinoline and deoxypyridinoline levels were not significantly affected. Budesonide (BUD) appeared to be the ICS inducing the less deleterious effects on bone, followed by beclomethasone dipropionate (BDP) and triamcinolone (TRI). Publication bias investigation provided non-significant results. In our meta-analyses, BUD at a mean daily dose (SD) of 686 microg (158 microg), BDP at 703 microg (123 microg) and TRI at 1,000 microg (282 microg) were found to affect bone mineral density and markers in patients suffering from the two major respiratory diseases. These findings could have practical implication in the long-term management of asthmatic and COPD patients.

The risk of osteoporosis in Caucasian men and women with obstructive airways disease

PURPOSE

Because patients with obstructive airways disease may be susceptible to osteoporosis, we sought to determine the association between airflow obstruction and osteoporosis.

SUBJECTS AND METHODS

We analyzed data from Caucasian participants (n = 9502) in the Third National Health and Nutrition Examination Survey, conducted in the United States between 1988 and 1994. We used data from dual-energy x-ray absorptiometry measurements of the total femur to determine whether a study participant had osteoporosis (defined as total bone mineral density values < or =2.5 SD below the corresponding mean values from young, healthy participants). We calculated the odds ratio (OR) for osteoporosis in four lung function categories: none, mild, moderate, and severe airflow obstruction.

RESULTS

Overall, airflow obstruction was associated with increased odds of osteoporosis compared with without airflow obstruction (OR = 1.9; 95% confidence interval [CI]: 1.4 to 2.5). Participants with severe airflow obstruction were at especially increased risk (OR = 2.4; 95% CI: 1.3 to 4.4). Moderate but not mild airflow obstruction was also associated with osteoporosis.

CONCLUSION

Airflow obstruction was an important risk factor for osteoporosis in the study population. These data highlight the importance of measuring bone mineral density in those with moderate-to-severe airflow obstruction for the detection and prevention of osteoporosis-related morbidity.

A comparison of bone mineral density in elderly female patients with COPD and bronchial asthma

BACKGROUND

A recent study has shown that osteoporosis and vertebral fractures are quite common in patients with advanced COPD and showed a significant relationship to the mortality of these patients. These results suggested that management of osteoporosis in advanced COPD is an important intervention. But whether patients with COPD who had never received chronic systemic corticosteroids have a high incidence of osteoporosis and whether these patients require treatment strategies to decrease osteoporotic fracture is not yet known. Furthermore, it is unclear whether there are differences in terms of the degree of osteoporosis between patients with COPD and patients with bronchial asthma.

OBJECTIVES

To compare the degree of osteoporosis and bone metabolism markers between elderly women with COPD and those with bronchial asthma who had never received chronic systemic corticosteroids, and to determine the factors influencing bone metabolism in these patients.

DESIGN

Cross-sectional medical survey.

PATIENTS

A total of 44 elderly female patients with COPD (n = 20) or bronchial asthma (n = 24) who had not received chronic systemic corticosteroids were enrolled (mean +/- SEM age, 74.6 +/- 1.0 years).

MEASUREMENTS

Total body and lumbar bone mineral density (BMD) were measured by dual-energy x-ray absorptiometry, and the data were compared between the two groups. In addition, the association between bone mass and clinical variables was determined.

RESULTS

When lumbar BMD was expressed as a Z score, the Z scores of patients with COPD were significantly lower than those of patients with bronchial asthma (p < 0.01). The prevalence of osteoporosis was also significantly higher in patients with COPD (50% vs 21%, p < 0.05). In patients with COPD, body mass index was positively correlated with BMD in the lumbar spine (r = 0.55, p = 0.02) and total body (r = 0.49, p = 0.03). Other clinical, biochemical, and anthropometric variables were not correlated with BMD.

CONCLUSIONS

In elderly female patients, osteoporosis is more common in cases of COPD than in bronchial asthma, even if these patients had not received long-term systemic corticosteroids. The explanation for the higher prevalence of osteoporosis in COPD is still not known, but preventive strategies to decrease osteoporotic fractures should be added to the management of elderly patients with COPD.

Risk factors for osteoporosis in a subgroup of elderly men in a Veterans Administration nursing home

BACKGROUND

General risk factors for osteoporosis in men include cigarette smoking, alcohol consumption, and diseases known to affect calcium or bone turnover. The aim of this study was to determine the specific incidence and major risk factors for osteoporosis in those at high risk for falling in a Veterans Administration nursing home that included a high proportion of psychiatric patients.

METHODS

We performed a cross-sectional analysis of Veterans Administration Medical Center nursing home residents with high fall risk. Thirty-nine men with a previous episode of falling or who were considered to be at high fall risk were enrolled. A review of the medical histories and pertinent hormonal and biochemical laboratory values was performed. Bone mineral density was measured by performing dual energy x-ray absorptiometry for all participants.

RESULTS

We reviewed the medical records of 39 male nursing home residents with high fall risk. The patients' mean age was 74.7 +/- 6.8 years. A significant (p = 0.00045) association was found between chronic obstructive pulmonary disease and osteoporosis independent of oral corticosteroid use. Additional risk factors found to be associated with osteoporosis included hypogonadism, lower body weight, antipsychotic medication use, and smoking.

CONCLUSION

In a Veterans Administration nursing home population at high risk for falls, including psychiatric patients, chronic obstructive pulmonary disease independent of the use of corticosteroids, lower body weight, hypogonadism, use of antipsychotic medications, and smoking was found to be associated with osteoporosis.

COPD and osteoporosis

Osteoporosis, with resulting fractures, is a significant problem in patients with advanced COPD. The etiology for the bone loss is diverse but includes smoking, vitamin D deficiency, low body mass index, hypogonadism, sedentary lifestyle, and use of glucocorticoids. Effective strategies to prevent bone loss and/or to treat osteoporosis include calcium and vitamin D, hormone replacement when indicated, calcitonin, and bisphosphonate administration. However, many patients remain undiagnosed until their first fracture because of the lack of recognition of the disease. With an increased awareness by pulmonologists and the increased use of preventive strategies, the impact of osteoporosis on those patients with COPD should decrease.

Bone loss in patients with untreated chronic obstructive pulmonary disease is mediated by an increase in bone resorption associated with hypercapnia

This study sought to determine whether the bone loss in untreated chronic obstructive pulmonary disease (COPD) is associated with hypercapnia and/or respiratory acidosis. Bone mineral density (BMD) measured at the distal forearm of the nondominant arm (with peripheral quantitative computed tomography [pQCT]) and serum markers of bone turnover were determined in 71 male patients with untreated COPD and 40 healthy male subjects who matched the patients in age, weight, and body mass index (BMI). The COPD patients, compared with controls, had reduced pulmonary functions, lower arterial pH, and elevated arterial partial pressure of CO2 (PCO2) The BMD (in T score) was significantly lower in COPD patients than that in control subjects (-1.628 +/- 0.168 vs. -0.058 +/- 0.157; p < 0.001). The BMD of COPD patients correlated positively with arterial pH (r = 0.582; p < 0.001), negatively with PCO2 (r = -0.442; p < 0.001), and negatively with serum cross-linked telopeptide of type I collagen (ICTP), a bone resorption marker (r = -0.444; p < 0.001) but not with serum osteocalcin, a bone formation marker. Serum ICTP, but not osteocalcin, correlated with PCO2 (r = 0.593; p < 0.001) and arterial pH (r = -0.415; p < 0.001). To assess the role of hypercapnia, COPD patients were divided into the hypercapnic (PCO2 > 45 mm Hg; n = 35) and eucapnic (PCO2 = 35-45 mm Hg) group (n = 36). Patients with hypercapnia had lower BMD, lower arterial pH, and higher serum ICTP than did patients with eucapnia. Arterial pH and serum ICTP of eucapnic patients were not different from those of controls. To evaluate the role of uncompensated respiratory acidosis, COPD patients with hypercapnia were subdivided into those with compensatory respiratory acidosis (pH > or = 7.35; n = 20) and those with uncompensated respiratory acidosis (pH < 7.35; n = 15). The BMD and serum ICTP were not different among the two subgroups. In conclusion, this study presents the first associative evidence that the bone loss in COPD is at least in part attributed to an increased bone resorption that is associated primarily with hypercapnia rather than uncompensated respiratory acidosis.

Use of inhaled corticosteroids and risk of fractures

Treatment with systemic corticosteroids is known to increase the risk of fractures but little is known of the fracture risks associated with inhaled corticosteroids. A retrospective cohort study was conducted using a large UK primary care database (the General Practice Research Database [GPRD]). Inhaled corticosteroid users aged 18 years or older were compared with matched control patients and to a group of noncorticosteroid bronchodilator users. Patients with concomitant use of systemic corticosteroids were excluded. The study comprised 170,818 inhaled corticosteroid users, 108,786 bronchodilator users, and 170,818 control patients. The average age was 45.1 years in the inhaled corticosteroid, 49.3 years in the bronchodilator, and 45.2 years in the control groups. In the inhaled corticosteroid cohort, 54.5% were female. The relative rates (RRs) of nonvertebral, hip, and vertebral fractures during inhaled corticosteroid treatment compared with control were 1.15 (95% CI, 1.10-1.20), 1.22 (95% CI, 1.04-1.43), and 1.51 (95% CI, 1.22-1.85), respectively. No differences were found between the inhaled corticosteroid and bronchodilator groups (nonvertebral fracture RR = 1.00; 95% CI, 0.94-1.06). The rates of nonvertebral fractures among users of budesonide (RR = 0.95; 95% CI, 0.85-1.07) and fluticasone propionate (RR = 1.03; 95% CI, 0.71-1.49) were similar to the rate determined for users of beclomethasone dipropionate. We conclude that users of inhaled corticosteroids have an increased risk of fracture, particularly at the hip and spine. However, this excess risk may be related more to the underlying respiratory disease than to inhaled corticosteroid.

Extrapulmonary effects of chronic obstructive pulmonary disease

Although airflow obstruction is the most obvious and most studied manifestation of chronic obstructive pulmonary disease (COPD), it should not be overlooked that COPD, particularly in its later stages, is associated with many extrapulmonary features that contribute to the morbidity, reduced quality of life, and, possibly, mortality of this disease. We review here the literature on skeletal muscle dysfunction, osteoporosis, and weight loss in COPD, with particular attention to possible approaches to their management. Patients with COPD may also have other extrapulmonary effects such as hormonal abnormalities that could probably be corrected, but less is known about them. COPD, therefore, should be regarded as a systemic disorder. Its systemic manifestations should not be overlooked in the overall care of the patient, because there are important ways in which they can be addressed.

Controlled short-term trial of fluticasone propionate in ventilator-dependent patients with COPD

BACKGROUND

There is no agreement about the efficacy of systemic corticosteroids in patients with COPD, but corticosteroids often are employed during exacerbations of the disease. The use of systemic or inhaled corticosteroids in patients in stable condition is even more controversial, even though the more severely affected patients seem to respond better. Unfortunately, in this subset of patients, the use of forced expiratory maneuvers frequently fails to detect significant functional response.

STUDY OBJECTIVES

We evaluated the short-term effects of an inhaled corticosteroid, fluticasone propionate (FP), on FEV(1) and on the mechanical properties of patients in stable condition with severe COPD and chronic hypercapnic respiratory failure who were receiving long-term ventilatory support. This allowed us to measure respiratory mechanics (RM) passively, thereby avoiding any problems linked with voluntary maneuvers.

DESIGN

Randomized, placebo-controlled, crossover study.

SETTING

A respiratory ICU.

PATIENTS

Twelve hypercapnic COPD patients (mean [+/- SD] PaCO(2), 60+/-11 mm Hg; mean FEV(1), 13+/-5% predicted; and mean FEV(1)/FVC, 31 +/- 7%) were enrolled.

INTERVENTIONS

A daily dose of 2,000 microg FP or placebo was administered via metered-dose inhaler during mechanical ventilation for 5 consecutive days. A washout of 72 h was allowed between regimens.

MEASUREMENTS

End-expiratory and end-inspiratory airway occlusions were performed to assess static intrinsic positive end-expiratory pressure (PEEPi,st), static compliance of the respiratory system (Cst,rs), maximal respiratory resistance (Rmax, rs), and minimal respiratory resistance (Rmin,rs). The bronchodilator response also was assessed by FEV(1) level.

RESULTS

No significant changes were found in RM after administration of the placebo. By day 6, FP had induced the following significant decreases: PEEPi,st, 4.3+/-2.4 to 3.1+/-1.7 cm H(2)O (p<0.01); Rmax,rs, 19.0+/-6.5 to 14.6+/-6 cm H(2)O/L/s (p<0.001); and Rmin,rs, 14.8+/-4.2 to 10.5+/-3.4 cm H(2)O/L/s (p<0.001). The Cst,rs and the effective additional resistance of the respiratory system did not change significantly, the latter suggesting that the major effect of FP was on the airway caliber (Rmin,rs). FEV(1) changes significantly (p<0.01) underestimated the bronchodilator response, as compared with changes in Rmin,rs.

CONCLUSIONS

We conclude that in patients in stable condition with severe COPD and chronic hypercapnic respiratory failure, a brief trial of FP may induce a bronchodilator response, mainly related to a reduction in airway resistances, that is not detected by the usual pulmonary function tests.

Secondary osteoporosis and the risk of vertebral deformities in women

Among an age-stratified sample of 942 Rochester, MN women, the overall prevalence of any vertebral deformity, as assessed by radiographic morphometry, was 21.3 per 100. The prevalence increased with age and, after adjusting for age, vertebral deformities were independently associated with height, weight, a history of distal forearm or hip fractures, and anticoagulant use. Altogether, 73% of the women with a vertebral deformity and 66% of controls had one or more of the conditions that have been linked with secondary osteoporosis, which in aggregate were associated with an age-adjusted 1.2-fold (95% CI 0.8-1.7) increase in risk that was not statistically significant. The prevalence of severe vertebral deformities was 11.7 per 100 women and the prevalence of very severe deformities was 5.7 per 100. There was a stronger relationship of age and most other risk factors with severe vertebral deformities than with isolated mild deformities, suggesting that a subset of mild deformities may not represent actual vertebral fractures. The metabolic disorders linked with secondary osteoporosis were associated with little increase in the risk of severe vertebral deformities, taken together, or of mild deformities. However, in aggregate these conditions were associated with a 2.3-fold increase (95% 1.1-4.8) in very severe vertebral deformities, which points to a role for rapid cancellous bone loss among women with the worst spinal osteoporosis.

Association between corticosteroid use and vertebral fractures in older men with chronic obstructive pulmonary disease

Osteoporosis is a major complication of long-term corticosteroid administration, but the magnitude of the effect in patients with chronic obstructive pulmonary disease (COPD) is not well defined. In a cross-sectional study, we evaluated the association between steroid use and vertebral fractures in 312 men, 50 yr of age or older, with COPD. Subjects were evaluated according to their corticosteroid use: Never Steroid Users (NSU) (n = 117), Inhaled Steroid Users (ISU) (n = 70), and Systemic Steroid Users (SSU) (n = 125). The prevalence of one or more vertebral fractures was 48.7% in the NSU group, 57.1% in the ISU group, and 63.3% in the SSU group. Compared with NSU, SSU were two times as likely to have one or more vertebral fractures: age-adjusted odds ratio (OR) = 1.80; 95% CI, 1.08 to 3.07. This relationship was primarily due to a strong association between continuous systemic steroid use and vertebral fractures: age-adjusted OR = 2.36; 95% CI, 1.26 to 4.38. In addition, fractures in SSU were more likely to be multiple and more severe. A weaker relationship existed between inhaled steroid use and vertebral fractures: age-adjusted OR = 1.35; 95% CI, 0.77 to 2.56 compared with NSU. These data indicate that vertebral fractures are common in older men with COPD; the likelihood of these fractures is greatest in those men using continuous systemic steroids.

Osteoporosis in lung transplantation candidates with end-stage pulmonary disease

PURPOSE

Fractures, a common complication of cardiac and liver transplantation, have not been reported in association with lung transplantation. However, many patients with end-stage pulmonary disease have multiple risk factors for osteoporosis, and several studies have suggested that osteoporosis before transplantation may increase the risk of fracture after transplantation. Therefore, we evaluated a group of patients with end-stage pulmonary disease who were awaiting lung transplantation to determine the prevalence of osteoporosis.

METHODS

Seventy patients (aged 18-70 years) were evaluated consecutively with bone densitometry by dual-energy x-ray absorptiometry. The patients were predominantly Caucasian (96%). Bone mass was expressed as bone mineral density (BMD; g/cm2), as the number of standard deviations (SD) below peak bone mass (T score), and as bone mineral apparent density (BMAD; g/cm3), a measurement that minimizes the effects of bone size on BMD. Spine radiographs were obtained in a subset of 50 consecutive patients to detect vertebral compression fractures. Vitamin D status was assessed with serum concentrations of 25-hydroxyvitamin D. The patients were sorted into groups by pulmonary diagnosis: chronic obstructive pulmonary disease (COPD; n = 28); cystic fibrosis (n = 11); idiopathic pulmonary fibrosis; and other lung diseases (Other; n = 31).

RESULTS

In the group as a whole, osteoporosis (T score below -2.5) was present in 30% of the patients at the lumbar spine and 49% at the femoral neck. Osteopenia (T score between -1 and -2.5) was present in an additional 35% at the lumbar spine and 31% at the femoral neck. The average femoral neck T score of patients with COPD and cystic fibrosis fell into the osteoporotic range (-2.7 +/- 0.3 and -2.6 +/- 0.3, respectively), significantly (P < 0.01) below that of the patients in the Other category (-1.5 +/- 0.3). The average lumbar spine T score fell into the osteopenic range in all three groups. Low BMAD in patients with cystic fibrosis confirmed that their low BMD was not due to their smaller body size. The prevalence rate of vertebral fractures was 29% in patients with COPD and 25% in those with cystic fibrosis. Vitamin D deficiency (25-hydroxyvitamin D levels < or = 10 ng/ml) was present in 36% of patients with cystic fibrosis and 20% with COPD and Other lung diseases. Lumbar spine BMD tended to be lower in cystic fibrosis patients with vitamin D deficiency. Patients with exposure to glucocorticoids (n = 46) had significantly more vertebral fractures (P < 0.05) and duration of exposure correlated negatively with lumbar spine BMD (r = -0.398; P = 0.008). COPD and Other patients not on glucocorticoids had mild lumbar spine osteopenia (0.972 +/- 0.06 g/cm2; T = -1.2 +/- 0.6). Very few of the patients on glucocorticoids were on any regimen to prevent osteoporosis.

CONCLUSIONS

Osteoporosis and vitamin D deficiency are extremely common in patients with end-stage pulmonary disease. Only 34% of patients had normal lumbar spine BMD and only 22% had normal BMD at the hip. Patients with cystic fibrosis and glucocorticoid-treated patients with COPD were most severely affected. Therapies to prevent bone loss and treat established osteoporosis are uncommonly utilized in glucocorticoid-treated patients with end-stage pulmonary disease. Candidates for lung transplantation should be evaluated for osteoporosis and vitamin D deficiency at the time of acceptance to the transplant waiting list.

Predictors of hip fractures in elderly men

To assess the influence on the risk of hip fractures in men of medical conditions associated with secondary osteoporosis or with an increased likelihood of falling, we conducted a population-based nested case-control study among the 232 Rochester, Minnesota, men with an initial hip fracture due to moderate trauma in 1965-1989 and an equal number of age-matched control men from the general population. Information on selected medical and surgical conditions and certain behavioral risk factors prior to fracture (or comparable index date for controls) was obtained from inpatient and outpatient medical records in the community that averaged over 36 years in duration. After adjusting for age, obesity, and inactivity, disorders linked with secondary osteoporosis were associated with a 2-fold increase in the risk of hip fracture in men (odds ratio [OR] 2.3; 95% confidence interval [CI] 1.3-4.3), while conditions linked with an increased risk of falling were associated with almost a 7-fold increase in risk (OR 6.9; 95% CI 3.3-14.8). These factors together appeared to account for about 72% of the hip fractures in men. Increased attention must be paid to these conditions which, in aggregate, are very common in elderly men and lead to a substantial increase in the risk of hip fracture with its devastating sequelae of death, disability and cost.

The effect of long- and short-term corticosteroids on plasma calcitonin and parathyroid hormone levels

The role of calcitonin and parathyroid hormone (PTH) in corticosteroid-induced osteoporosis is controversial. We therefore measured plasma calcitonin and PTH levels in 34 adults receiving chronic pharmacological corticosteroids for obstructive airways disease, and in controls matched for age, sex, menopause, and disease. In addition, the acute effect of a 7-day course of 15 mg prednisolone daily on fasting and calcium-stimulated calcitonin was studied in 10 normal male volunteers. There was no difference in calcitonin and PTH levels in the corticosteroid-treated patients when compared with controls. The corrected serum calcium was significantly higher in the steroid-treated patients (patients mean 2.40 (SEM 0.01) mmol/liter; controls mean 2.33 (SEM 0.01) mmol/liter; P < 0.001). The short course of corticosteroids in volunteers did not alter basal or stimulated calcitonin, PTH, or calcium levels. These results suggest that neither calcitonin deficiency nor PTH excess is a feature of corticosteroid-induced osteoporosis.

Risk of osteoporosis in men with chronic bronchitis

Theoretically, patients with chronic bronchitis are at risk for osteoporosis. Bone metabolism was assessed in 44 male chronic bronchitics treated with oral prednisolone (C+; n = 19) or with bronchodilatory drugs alone (C-; n = 25). In both groups, serum osteocalcin was lower (p less than 0.001) than in age- and sex-matched controls (mean (ng/ml) C+ 1.0, C- 1.9, controls 4.2), while testosterone was at the lower limit of the reference range. Low trabecular bone mineral density (BMD) was noted in the C- group (median Z score -1.0), but both cortical and trabecular BMD were depressed in the C+ group (-1.0 and -1.4, respectively). In conclusion, chronic bronchitics treated with corticosteroids, even at low doses, are at risk for osteoporosis. In both groups, additional factors such as hypogonadism might be responsible for low BMD and low osteocalcin levels. A decrease in bone formation is a possible mechanism of action.

Vitamin D status in children with Down's syndrome

The serum levels of the active Vitamin D metabolites 25-hydroxyvitamin D[25(OH)D], 1,25-dihydroxyvitamin D[1,25(OH)2D] and 24,25 dihydroxyvitamin D [24,25(OH)2D], were studied in 21 children with Down's syndrome (DS) in Cantabria, a northern region of Spain, located at 44 degrees N latitude. Serum calcium, magnesium, phosphate, alkaline phosphatase, parathormone and osteocalcine were also determined. In the DS group, the average values of the three Vitamin D metabolites were comparable to those of an age-matched group both in winter and summer times. No child with DS showed values below the normal range, either in Vitamin D metabolites, or in the other parameters of calcium metabolism. The normal increment of 25(OH)D and 24,25(OH)2 values from March to October was not observed in five children. This anomaly was corrected in three, after adequate rules of sun exposure during summer time were followed. In the other two, the 25(OH)D levels were high throughout the study. This investigation shows that children with DS do not require Vitamin D prescription when appropriate periods of sunlight exposure are provided.

Vertebral fractures in steroid dependent asthma and involutional osteoporosis: a comparative study

BACKGROUND

Reduced bone mass predisposes patients to the development of vertebral fractures. Measurement of bone mass by non-invasive methods is used to detect patients with involutional osteoporosis at risk from fractures. These methods have not been assessed in patients with steroid dependent osteoporosis. The objective of this study was to assess the value of a predictive fracture threshold value of bone density in patients with steroid dependent asthma.

METHODS

Three groups of patients were studied. Group 1 (67 patients) had steroid dependent asthma (mean daily dose of prednisone 11.7 mg) and no vertebral fractures, group 2 (32 patients) had steroid dependent asthma (mean daily dose of prednisone 12 mg) and vertebral fractures, and group 3 (55 patients) were not taking steroids but had involutional osteoporosis and a recent non-traumatic vertebral fracture. Bone mineral density was measured by dual photon absorptiometry and vertebral fractures by radiography of the lumbar spine. A fracture threshold was determined in the two groups with fractures as the 90th percentile of the mean bone mineral density measured in the lumbar spine.

RESULTS

Bone mineral density was significantly higher in the steroid dependent group with fractures (group 2) than in group 3 patients, who had involutional osteoporosis and fractures (0.946 (0.18) g/cm2 v 0.830 (0.16) g/cm2). The fracture threshold value was therefore higher for patients with steroid related vertebral fractures (group 2, 1.173 g/cm2) than for those with involutional osteoporosis (group 3, 0.979 g/cm2). Vertebral fractures were more likely to occur in steroid dependent asthmatic patients with bone density above the fracture threshold value (obtained from subjects with involutional osteoporosis) than in subjects in group 3 (34% v 9%).

CONCLUSION

Vertebral fractures occur in patients treated with steroids in the presence of higher bone mineral density than is the case with patients with involutional osteoporosis. The findings suggests that the assessment of the efficacy of preventive treatment requires measurement of bone mineral density and radiology.