Severity and pattern of bone mineral loss in endocrine causes of osteoporosis as compared to age-related bone mineral loss

Vitamin D in pituitary driven osteopathies

The evidence that pituitary hormones may bypass peripheral endocrine glands to exert remarkable effects on the skeleton is gaining ground. Both hormonal excess and deficit may determine impairment in bone structure, and they commonly result in bone loss in patients affected by pituitary and neuroendocrine disorders. Vertebral fractures are the most common skeletal alterations and may occur independently of bone mass. Use of vitamin D (VD) supplementation is still debated in this setting. This review will focus on the interactions between different metabolites of VD and pituitary hormones, and the effects of VD supplementation on bone metabolism in patients with pituitary diseases.

Occurrence & predictors of osteoporosis & impact of body composition alterations on bone mineral health in asymptomatic pre-menopausal women with HIV infection

Background & objectives:

Data on bone mineral density (BMD) and sarcopenia are scant from young females with HIV. This study was conducted to determine occurrence, predictors and impact of body composition alterations on osteoporosis in pre-menopausal women with HIV.

Methods:

A total of 214 females with serologically documented HIV infection were screened, of whom 103 pre-menopausal women, 25-45 yr age, clinically stable, having at least one year follow up data, underwent hormonal and dual-energy X-ray absorptiometry analysis for BMD and body composition. Seventy five matched controls were also evaluated.

Results:

Females with HIV had significantly lower BMD and Z-score at lumbar spine (LS), total femur, neck of femur (NOF), and radius ultra-distal (UD) compared to controls. Osteoporosis at least at one site was observed in 34.95 per cent patients, compared to eight per cent in controls (P <0.001). Most common site of osteoporosis in females with HIV was radius UD (24.27%), followed by radius 33 per cent (17.48%), radius total (15.53%) and greater trochanter, NOF and LS (6.80% each). HIV patients had significantly lower bone mineral content, lean mass (LM), fat per cent, android (A) fat, gynoid (G) fat, and A/G ratio. LM and fat mass (FM) were −15.65 and −11.54 per cent lower in HIV patients, respectively. Osteoporosis patients had significantly higher use of antiretroviral therapy and lower LM, FM and fat per cent. On logistic regression, LM followed by A/G ratio and BMI were the best predictors of osteoporosis. Sarcopenia was observed in 17.5 per cent patients.

Interpretation & conclusions:

Our results showed that osteoporosis and sarcopenia were significant problems in young women with HIV. HIV was associated with greater LM loss, which was critical for bone health. Sarcopenia may predict low BMD in HIV.

18F-Fluorocholine-Positron Emission Tomography/Computerised Tomography is Useful in Localising 99mTc-Sesta-methoxyisobutylisonitrile-Negative Parathyroid Cyst Causing Normocalcemic Primary Hyperparathyroidism

Parathyroid cysts are extremely rare and are rarely associated with primary hyperparathyroidism (PHPT), which are difficult to localise, as they are ^99mTc-sesta-methoxyisobutylisonitrile (sestaMIBI) negative. We report for the first time the utility of ¹⁸F-fluorocholinepositron emission tomography/computerised tomography (PC-PET/CT) in localising parathyroid cyst causing normocalcemic PHPT. A 76-year-old lady with progressively worsening osteoporosis from 2014–2017 (in spite of annual zolendronic acid infusions, daily calcium and vitamin-D supplementation) with persistently normal serum calcium and vitamin D, but elevated parathyroid hormone, had normal sestaMIBI scans of the neck on multiple occasions. FC-PET/CT finally revealed soft tissue uptake, suggestive of right superior parathyroid adenoma/ hyperplasia. Surgical removal of the culprit lesion resulted in resolution of hyperparathyroidism, histopathologic evaluation of which revealed a cystic lesion lined by chief cell variant parathyroid cells without any nuclear atypia, capsular or vascular invasion. FC-PET/CT is useful in localising culprit parathyroid lesions, especially when they are sestaMIBI negative. PC-PET/CT is useful in localising parathyroid hyperplasia and ectopic parathyroids, which are frequently missed by sestaMIBI. There is an urgent need for comparative studies between sestaMIBI and FC-PET/CT in PHPT. We report for the first time the usefulness of FC-PET/CT in localising sestaMIBI-negative functional parathyroid cyst causing normocalcemic PHPT.

Lean Mass and Disease Activity are the Best Predictors of Bone Mineral Loss in the Premenopausal Women with Rheumatoid Arthritis

BACKGROUND AND OBJECTIVES

Factors determining bone mineral (BM) loss in rheumatoid arthritis (RA) are not well known. This study aimed to determine the occurrence and predictors of BM loss in the young premenopausal women with RA.

METHODS

Ninety-six females with RA and 90 matched controls underwent clinical, biochemical, BM density (BMD), and body composition assessments. RA disease activity was assessed using disease activity score-28 (DAS-28) and hand X-ray.

RESULTS

In the young premenopausal females with RA having median symptom and treatment duration of 30 (18-60) and 4 (2-12) months, respectively, with moderate disease activity (DAS-28, 4.88 ± 1.17), occurrence of osteoporosis and osteopenia was 7.29% and 25% at spine, 6.25% and 32.29% at hip, and 17.7% and 56.25% at wrist, respectively (significantly higher than controls). RA patients had lower BMD at total femur, lumbar spine (LS), radius total, and radius ultra-distal. Total lean mass (LM) and BM content were significantly lower in RA (P = 0.022 and <0.001, respectively). In RA, BMD at majority of sites (LS, neck of femur, greater trochanter, radius total, and radius 33%) had the strongest positive correlation with LM followed by body fat percent. RA patients with most severe disease had lowest BMD at different sites and lowest LM. Stepwise linear regression revealed LM followed by DAS-28 to be best predictors of BMD. RA patients receiving glucocorticoids did not have significantly different BMDs from patients not taking glucocorticoids.

INTERPRETATION AND CONCLUSION

BM loss is a significant problem in the young premenopausal women with recent-onset RA. LM and disease severity were the best predictors of BMD.

A 2016 clinical practice pattern in the management of primary hypothyroidism among doctors from different clinical specialties in New Delhi

BACKGROUND

This study aimed to document practices in managing hypothyroidism among doctors in New Delhi, with special focus on subclinical hypothyroidism, pregnancy, and old age, and to compare it with global practices.

METHODS

During an academic program attended by 394 doctors, all participants were given a questionnaire designed based on thyroid practices survey done by Burch et al. to evaluate the practice patterns. Questions were based on evaluating doctor's preferred choices in diagnosis, therapy, and follow-up of hypothyroidism in different scenarios.

RESULTS

Responses from 308 questionnaires (general physicians [n = 204], obstetricians [n = 51], pediatricians [n = 27], surgeons [n = 12], endocrinologists [n = 10], and others [n = 4]) were analyzed. In the evaluation of 52-year-old female patient with primary hypothyroidism, 52% doctors would prefer thyroid ultrasonography, comparable to global rates. Nearly 96.1% doctors would have initiated levothyroxine, with a large majority of doctors (83.77%) preferred using branded levothyroxine. About 58.74% doctors preferred gradual restoration of euthyroidism. Levothyroxine dose of 25 mcg was the most preferred increment dose (46.07%) during follow-up, with 6 weekly being the most frequent dose adjustment frequency (41.57%). Most preferred target thyroid-stimulating hormone (TSH) in the 52-year-old female patient was 2.5-4.99 mU/L (63.96%), 25-year-old female patient was 1-2.49 mU/L (53.90%), and in 85-year-old female was 2.5-4.99 mU/L (45.45%). Only 68% of doctors in our study preferred keeping TSH <2.5 mU/L during the first trimester of pregnancy, in contrast to global trends of 95% (P < 0.001).

CONCLUSION

There was a disproportionately high use of ultrasonography in hypothyroidism management, near exclusive preference for branded levothyroxine, widespread use of age-specific TSH targets, and low threshold for treating mild thyroid failure, a highly variable approach to both rates and means of restoring euthyroidism for overt primary hypothyroidism. There is a need for spreading awareness regarding TSH targets in pregnancy.