The effect of 8 or 5 years of denosumab treatment in postmenopausal women with osteoporosis: results from the FREEDOM Extension study

The FREEDOM study and its Extension provide long-term information about the effects of denosumab for the treatment of postmenopausal osteoporosis. Treatment for up to 8 years was associated with persistent reduction of bone turnover, continued increases in bone mineral density, low fracture incidence, and a favorable benefit/risk profile.

INTRODUCTION

This study aims to report the results through year 5 of the FREEDOM Extension study, representing up to 8 years of continued denosumab treatment in postmenopausal women with osteoporosis.

METHODS

Women who completed the 3-year FREEDOM study were eligible to enter the 7-year open-label FREEDOM Extension in which all participants are scheduled to receive denosumab, since placebo assignment was discontinued for ethical reasons. A total of 4550 women enrolled in the Extension (2343 long-term; 2207 cross-over). In this analysis, women in the long-term and cross-over groups received denosumab for up to 8 and 5 years, respectively.

RESULTS

Throughout the Extension, sustained reduction of bone turnover markers (BTMs) was observed in both groups. In the long-term group, mean bone mineral density (BMD) continued to increase significantly at each time point measured, for cumulative 8-year gains of 18.4 and 8.3 % at the lumbar spine and total hip, respectively. In the cross-over group, mean BMD increased significantly from the Extension baseline for 5-year cumulative gains of 13.1 and 6.2 % at the lumbar spine and total hip, respectively. The yearly incidence of new vertebral and nonvertebral fractures remained low in both groups. The incidence of adverse and serious adverse events did not increase over time. Through Extension year 5, eight events of osteonecrosis of the jaw and two events of atypical femoral fracture were confirmed.

CONCLUSIONS

Denosumab treatment for up to 8 years was associated with persistent reductions of BTMs, continued BMD gains, low fracture incidence, and a consistent safety profile.

Zoledronic acid results in better health-related quality of life following hip fracture: the HORIZON-Recurrent Fracture Trial

This study evaluated the benefits of ZOL versus placebo on health-related quality of life (HRQoL) among patients from HORIZON-RFT. At month 24 and end of the study visit, ZOL significantly improved patients' overall health state compared to placebo as assessed by the EQ-5D VAS.

INTRODUCTION

To evaluate the benefits of zoledronic acid (ZOL) versus placebo on health-related quality of life (HRQoL) among patients from The Health Outcomes and Reduced Incidence With Zoledronic Acid Once Yearly Recurrent Fracture Trial (HORIZON-RFT).

METHODS

In this randomized, double-blind, placebo-controlled trial, 2,127 patients were randomized to receive annual infusion of ZOL 5 mg (n = 1,065) or placebo (n = 1,062) within 90 days after surgical repair of low-trauma hip fracture. HRQoL was measured using EQ-5D Visual Analogue Scale (VAS) and utility scores (EuroQol instrument) at months 6, 12, 24, 36, and end of the study visit. Analysis of covariance model included baseline EQ-5D value, region, and treatment as explanatory variables.

RESULTS

At baseline, patients (mean age 75 years; 24% men and 76% women) were well matched between treatment groups with mean EQ-5D VAS of 65.82 in ZOL and 65.70 in placebo group. At the end of the study, mean change from baseline in EQ-5D VAS was greater for ZOL vs. placebo in all patients (7.67 ± 0.56 vs. 5.42 ± 0.56), and in subgroups of patients experiencing clinical vertebral fractures (8.86 ± 4.91 vs. -1.69 ± 3.42), non-vertebral fractures (5.03 ± 2.48 vs. -1.07 ± 2.16), and clinical fractures (5.19 ± 2.25 vs. -0.72 ± 1.82) with treatment difference significantly in favor of ZOL. EQ-5D utility scores were comparable for ZOL and placebo groups, but more patients on placebo consistently had extreme difficulty in mobility (1.74% for ZOL vs. 2.13% for placebo; p = 0.6238), self-care (4.92% vs. 6.69%; p = 0.1013), and usual activities (10.28% vs. 12.91%; p = 0.0775).

CONCLUSION

ZOL significantly improves HRQoL in patients with low-trauma hip fracture.

Epidemiology of hip fracture in Tucuman, Argentina

The incidence of osteoporotic hip fracture was studied previously in a central area of Argentina. Studying Tucuman (north area) was very useful to compare results of the different areas and detect a similar incidence in women and a slightly higher incidence in men compared with previous data for the central region.

INTRODUCTION/METHODS

Epidemiology of hip fracture was studied over a 1-year period in the city of San Miguel de Tucumán (SMT) and in the whole province of Tucumán, located in the northeast of Argentina (latitudes 26° and 28° south). The results were compared with previous studies performed in the central region of Argentina.

RESULTS

Two hundred and eighty-three patients (208 women and 75 men) aged 50 years or over in SMT suffered a hip fracture. The incidence in females and males was 334.9 and 163.8 hip fractures per 100,000 inhabitants per year, respectively (female/male ratio 2.0). A total of 498 hip fractures were recorded in Tucuman province (367 in women and 131 in men). The results in females and males were 276.5 and 114.7 hip fractures per 100,000 inhabitants per year, respectively. Average age of the female and male population was 78±9 and 77±9 years, respectively.

CONCLUSIONS

These results showed that the incidence of hip fracture in female and male populations in SMT was similar to previous studies performed in the central area of the country. Further studies on the south area of Argentina should be conducted to complete the information on a large country extending from latitudes 22° to 55°S.

Low levels of endogenous estradiol protect bone mineral density in young postmenopausal women

OBJECTIVE

Low levels of endogenous estrogens may play a role in the protection of bone mineral density (BMD) in healthy postmenopausal women. The aim of this study was to evaluate the effect of endogenous estradiol and testosterone on bone mass in young and older healthy postmenopausal women.

METHODS

The study involved 99 postmenopausal women aged 55-75 years. The BMDs of the lumbar spine, proximal femur and total skeleton were determined. Measurements were taken of serum calcium, bone alkaline phosphatase, Crosslaps, estradiol, estrone, sex hormone binding globulin, testosterone, bioavailable testosterone and urine calcium. Estradiol was measured using a sensitive assay with a lower detection limit at 5 pg/ml.

RESULTS

A multivariate analysis showed that the BMD of the lumbar spine was significantly predicted by estradiol (p < 0.05), and testosterone (p < 0.0001). Likewise, testosterone was found to be an independent predictor of the BMD of the total femur (p < 0.001) and the total skeleton (p < 0.001). The population was divided into two groups: < or = 65 (Group 1) and > 65 years (Group 2) of age and also stratified according to estradiol levels: > 10 and < or = 10 pg/ml. Significant differences in BMD were found in women in Group 1 in whom estradiol levels higher than 10 pg/ml were associated with a higher BMD of the lumbar spine (+ 14%, p < 0.01), proximal femur (+ 6%, p < 0.05) and total skeleton (+ 7%, p < 0.05) compared with women with estradiol levels below 10 pg/ml. Bone alkaline phosphatase levels (p < 0.05) and serum Crosslaps (not significant) were lower in women in Group 1 with a level of estradiol more than 10 pg/ ml.

CONCLUSION

Endogenous estradiol levels higher than 10 pg/ml and testosterone protected bone mass in healthy postmenopausal women under 65 years of age. These results were not observed in the group of older women.

Bone mineral density in children with celiac disease. Effect of a Gluten-free diet

OBJECTIVE

To assess the degree of osteopenia in children with celiac disease (CD) at the time of diagnosis and the effect of a gluten-free diet (GFD).

DESIGN

Longitudinal and prospective study.

SUBJECTS

In total, 24 children (18 girls, six boys) diagnosed with CD by means of an intestinal biopsy were included in the study. Mean+/-s.d. age was 4.9+/-4.3 years. In all, 16 patients were under (2.20+/-0.82 year) and eight were over the age of 4 years (10.30+/-2.90 year). The time between the first symptoms and diagnosis was 17.30+/-24.70 months (range: 2-109 months). Spine bone mineral content (BMC), area and bone mineral density (BMD) were measured by DXA at baseline and 1.17+/-0.93 years after GFD.

RESULTS

Before treatment, mean+/-s.d. BMD was 0.46+/-0.13 g/cm(2), the BMD Z-score was -1.36+/-1.20, and was below -1 s.d. in 14 patients (58%). BMC, area and BMD increased significantly on GFD. BMD increased from 0.46+/-0.13 to 0.55+/-0.13 g/cm(2) (P<0.001). BMD Z-score improved from -1.36+/-1.20 to -0.23+/-1.20 after GFD. However, BMD increased more than 1 s.d. in 15 of the 16 children under the age of 4 years, a similar increase was only observed in four of the eight children aged more than 4 years, some of whom did not follow GFD strictly. Height and weight increased significantly with GFD (P<0.001) and the increase correlated positively with the increase in BMD.

CONCLUSIONS

Axial BMD below -1 s.d. was found in 58% of children with celiac disease. Axial bone mass reverted to normal values in most children under the age of 4, who had low bone mass, all of whom followed GFD strictly.

Long-term control of hypercalcaemia in an infant with williams-Beuren syndrome after a single infusion of biphosphonate (Pamidronate)

AIM

To report the efficacy of Pamidronate to treat hypercalcaemia in a patient with Williams-Beuren syndrome (WBS).

RESULTS

We report a 14-mo-old male infant presenting hypercalcaemia, elfin face and other dysmorphological features of WBS, confirmed by the FISH fluorescent test. Due to the marked symptomatic hypercalcaemia, 13.0 mg/dl intravenous Pamidronate was administered in a single dose of 1 mg/kg. Two days later, serum calcium diminished to normal levels, and remained within normal range during 12 mo follow-up.

CONCLUSION

Pamidronate appears to be effective in paediatric patients with WBS and hypercalcaemia.

Effect of doxercalciferol (1alpha-hydroxyvitamin D2) on PTH, bone turnover and bone mineral density in a hemodialysis patient with persistent secondary hyperparathyroidism post parathyroidectomy

The efficacy and safety of the vitamin D analog, doxercalciferol (1alpha-hydroxyvitamin D2, 1alphaD2) in the treatment of secondary hyperparathyroidism in hemodialysis patients has been previously reported. We report these effect of 16-week 1alphaD2 treatment on mineral metabolism and bone mineral density (BMD) in a hemodialysis patient with persistent secondary hyperparathyroidism post parathyroidectomy, resistant to previous calcitriol treatment. Levels of iPTH, bone-specific alkaline phosphatase and serum type I collagen C telopeptide were above normal at baseline and were substantially decreased with 1alphaD2 treatment (-92%, -63% and -53%, respectively). BMD increased in all areas: total skeleton (+6.5%), lumbar spine (+6.9%) and total femur (+4.3%). The patient showed no hypercalcemia, and phosphorus levels remained between 3.3 and 6.2 mg/dl.

Is it necessary to screen for celiac disease in postmenopausal osteoporotic women?

Decreased bone mass is a frequent finding in celiac patients, and subclinical celiac disease (CD) appears to be unusually overrepresented among patients with idiopathic osteoporosis. Since silent CD may be more common than previously believed, it has been suggested that all osteoporotic patients should be checked for occult CD. The aim of this study was to explore the prevalence of CD in a well-defined population of postmenopausal osteoporotic women. We evaluated 127 consecutive postmenopausal patients (mean age: 68 years; range: 50-82 years) with verified osteoporosis. The observed prevalence of CD in this group was compared to that observed in a group of 747 women recruited for a population-based study. The screening algorithm used to diagnose CD was based on a 3-level screening using type IgA and IgG antigliadin antibodies (AGA) in all the patients (1st level) followed by antiendomysial antibodies (EmA) and total IgA (2nd level) of samples testing positive, and intestinal biopsy of positive cases (3rd level). At the end of the serological screening, only 1 of 127 osteoporotic women was eligible for jejunal biopsy showing a characteristic celiac flat mucosa (prevalence 7.9 x 1,000; 95% CI 0.2-43.1). In addition, CD was diagnosed in 6 of 747 women of the population-based study (prevalence: 8.0 x 1,000; 95% CI 3.3-18.3). There was no significant difference between the two groups. Therefore, our study showed that the prevalence of CD in postmenopausal osteoporotic women was lower than that reported in previous studies and similar to that of the general population. In conclusion, although the relatively small size of the group tested does not allow us to be conclusive, the results suggest that a case finding policy in postmenopausal osteoporosis would have a high cost/benefit ratio except for patients not responding to conventional therapies, or presenting borderline laboratory results.

Olpadronate prevents the bone loss induced by cyclosporine in the rat

The aim of the present in vivo experimental study was to investigate changes in bone turnover and bone mineral density (BMD) induced by cyclosporine (CsA) administration. The effectiveness of olpadronate (OPD) in preventing bone loss associated with CsA treatment was also evaluated. Forty male Sprague-Dawley rats (approximately 5 months old) were treated as follows: Group I: CsA+OPD vehicles (control); Group II: CsA 15 mg/kg + OPD vehicle; Group III: CsA 15 mg/kg + 4 ug OPD/100g rat; Group IV: CsA 15 mg/kg + 8 ug OPD/100g rat; Group V: CsA 15 mg/kg + 16 ug OPD/100g rat. CsA was administered by daily oral gavage and OPD by intraperitoneal injection once a week. Serum bone-alkaline phosphatase (b-ALP) and urinary deoxypyridinoline (DPyr) were measured on days 0, 14 and 30. Total skeleton, femur, lumbar spine, proximal, and middle tibia BMDs were measured on days 0 and 30. No significant differences were found between the CsA and the control groups as regards serum bALP levels, on days 14 and 30. CsA+OPD treated rats presented a transient increment in serum b-ALP on day 14 and a significantly lower level on day 30 compared to the control and CsA groups (P < 0.05). On days 14 and 30, DPyr excretion increased in the CsA group compared to control animals (P < 0.05). The three studied doses of OPD induced a significant decrease in DPyr excretion in the CsA group on days 14 and 30 (P < 0.05). Group V (receiving the highest dose of OPD) presented a significantly lower level of DPyr compared to the other two OPD-treated groups (P < 0.05). On day 30, the CsA group presented a significant reduction in proximal tibia, spine and whole femur BMDs (P < 0.05) compared to controls. On day 30, OPD treatment increased BMD of all the studied areas in CsA rats. Proximal tibia BMD of group V reached significantly higher values than the other studied OPD groups (P < 0.05). In summary, this study suggests that CsA-induced high bone resorption and trabecular bone loss is prevented by cotreatment with OPD. Moreover, it encourages the possible use of OPD to treat patients receiving CsA as immunosuppressive therapy.

Effect of melatonin on bone metabolism in ovariectomized rats

To assess the effect of pharmacological dose of melatonin on bone metabolism in ovariectomized rats, urinary deoxypyridinoline (a marker of bone resorption) and calcium excretion, circulating levels of calcium, phosphorus and bone alkaline phosphatase activity (a marker of bone formation), and bone mineral density (BMD), mineral content (BMC) and bone area (BA) of total body, were measured in adult rats for up to 60 days after surgery. Rats received melatonin in the drinking water (25 microg/ml water) or drinking water alone. Urinary deoxypyridinoline increased significantly after ovariectomy by 51% (30 days after surgery) and by 47% (60 days after surgery). The increase in urinary deoxypyridinoline found 30 days after ovariectomy was not observed in melatonin-treated rats. Urinary calcium concentration was similar in the 4 experimental groups studied, as was the circulating calcium concentration at every time interval examined. Fifteen days after surgery, a significant increase in serum phosphorus and bone alkaline phosphatase levels occurred in ovariectomized rats receiving melatonin as compared to their controls. Sixty days after surgery BMD, BMC and BA decreased significantly in ovariectomized rats, an effect not modified by melatonin. Serum estradiol decreased significantly by 30 days after ovariectomy to attain values close to the limit of detection of the assay by 60 days after ovariectomy. The results support the conclusion that a pharmacological amount of melatonin modifies bone remodeling after ovariectomy and that the effect may need adequate concentrations of estradiol.

Do different aminobisphosphonates have similar preventive effect on experimental thyroid hormone-induced osteopenia in rats?

We compared similar doses of three different aminobisphosphonates (BP): olpadronate (OPD), pamidronate (APD), and alendronate (ALE) on osteopenia induced by thyroxine (T4)-treatment in OVX and SHAM adult rats. Female Sprague Dawley rats (259 +/- 8 g) were treated with vehicle (SHAM+Vh and OVX+Vh), 250 microg T4/kg/day (SHAM+T4 and OVX+T4), 0.3 mg OPD/kg/day (SHAM+OPD and OVX+OPD), 0.2 mg ALE/kg/day (SHAM+ALE and OVX+ALE), 1.5 mg APD/kg/day (SHAM+APD and OVX+APD), T4+OPD (SHAM+T4+OPD and OVX+T4+OPD), T4+ALE (SHAM+T4+ALE and OVX+T4+ALE), and T4 +APD (SHAM+T4+APD and OVX+T4+APD) during a 5-week period. At the onset and at the end of the experiment, total skeleton bone mineral density (BMD) was assessed in vivo by DXA. Lumbar spine and proximal tibia BMDs were evaluated. T4 treatment to SHAM rats did not modify BGP levels significantly: neither did ovariectomy. T4 treatment to OVX rats significantly increased bone-gla-protein (BGP) levels compared with the other studied groups (P < 0.05). BP treatment reduced BGP levels to values significantly lower than SHAM rats (P < 0.05) and reduced bone alkaline phosphatase in SHAM groups (P < 0.05) but no changes were found in OVX groups. The increased D-Pyr excretion observed in SHAM+T4 rats (P = 0.056), OVX+Vh (P < 0.05), and OVX+T4 group (P < 0.001) compared with the SHAM+Vh rats was prevented by the BP treatment. OVX+Vh rats had total skeleton and proximal tibia BMD, and OVX+T4 group had total skeleton, spine, and proximal tibia BMD significantly lower than the SHAM+Vh group. BP treatment was also found to prevent this reduction. The reduced bone resorption and the prevention of bone loss showed no differences among very close, potentially equivalent doses of the three aminoBPs used. Consequently, treatment with very close similar doses of APD, ODP, and ALE prevented bone resorption and bone changes with the same efficacy.

Body composition of professional football (soccer) players determined by dual X-ray absorptiometry

A three-compartment body composition analysis of 42 professional football (soccer) players and 33 age- and body mass index-matched control subjects was determined by dual X-ray absorptiometry (DXA). The equipment provided a direct measurement of fat, lean, and bone mass. Fat mass was significantly higher in the controls subjects whereas lean mass and bone mass were markedly higher in the players. The percentage of body weight fat varied from 6.1 to 19.5% in the football players and from 9.1 to 29.9% in the control subjects. The respective averages were 12.0 +/- 3.1 and 19.2 +/- 5.6% (p < 0.001). The midfielders had a significantly higher percentage of fat (13.6 +/- 3.3%) than backs or forwards (11.1 +/- 2.8 and 11.0 +/- 2.3%, p < 0.05 and p < 0.06, respectively). In the football players, the correlation between age and fat mass was significant (r = 0.53, p < 0.001), whereas there was no correlation between fat and age in the control subjects (r = 0.13 p > 0.1). This article provides, for the first time, DXA analysis of body composition of football players in relation to their age and function. The results should be of interest to coaches because they will help improve athletes' performance.

Osteoporosis with vertebral fractures associated with pregnancy and lactation

Three cases of young women who developed severe vertebral osteoporosis after pregnancy and during lactation are described. These patients shared several features: a low-calcium diet during most of their lives, very-low body weight in two patients, and a positive family history of osteoporosis in two patients. Initial studies disclosed vertebral fractures, severely diminished bone mineral density of the spine (Z score = -3.3 to -4.1), and a less severely affected bone mineral density of the hip (Z score = -1.6 to -2.3). During the prolonged follow-up of these patients, treated with oral biphosphonates, vitamin D, and calcium, an improved clinical response with a marked recovery of spine bone mineral density was observed. Poor general nutrition, low calcium intake, and a positive family history of osteoporosis appear to be strong risk factors for pregnancy- and lactation-associated osteoporosis. Although the mechanism of action is uncertain, calcium, vitamin D, and antiresorptive agents may have been beneficial in the treatment of this severe disorder.

Peripheral bone mass is not affected by winter vitamin D deficiency in children and young adults from Ushuaia

Low vitamin D levels in elderly people are associated with reduced bone mass, secondary hyperparathyroidism, and increased fracture risk. Its effect on the growing skeleton is not well known. The aim of this study was to evaluate the possible influence of chronic winter vitamin D deficiency and higher winter parathyroid hormone (PTH) levels on bone mass in prepubertal children and young adults. The study was carried out in male and female Caucasian subjects. A total of 163 prepubertal children (X age +/- 1 SD: 8.9 +/- 0.7 years) and 234 young adults (22.9 +/- 3.6 years) who had never received vitamin D supplementation were recruited from two areas in Argentina: (1)Ushuaia (55 degrees South latitude), where the population is known to have low winter 25OHD levels and higher levels of PTH in winter than in summer, and (2)Buenos Aires (34 degrees S), where ultraviolet (UV) radiation and vitamin D nutritional status in the population are adequate all year round. Bone mineral content (BMC) and bone mineral density (BMD) of the ultradistal and distal radius were measured in the young adults. Only distal radius measurements were taken in the children. Similar results were obtained in age-sex matched groups from both areas. The only results showing significant difference corresponded to comparison among the Ushuaian women: those whose calcium (Ca) intake was below 800 mg/day presented lower BMD and BMC values than those whose Ca intake was above that level (0.469 +/- 0.046 versus 0.498 +/- 0.041 g/cm(2), P < 0.02; 3.131 +/- 0.367 versus 3.339 +/- 0.386 g, P < 0.05, respectively). In conclusion, peripheral BMD and BMC were similar in children and young adults from Ushuaia and Buenos Aires in spite of the previously documented difference between both areas regarding UV radiation and winter vitamin D status. BMD of axial skeletal areas as well the concomitant effect of a low Ca diet and vitamin D deficiency on the growing skeleton should be studied further.

Differences in bone turnover and skeletal response to thyroid hormone treatment between estrogen-depleted and repleted rats

This study was undertaken to compare the effect of supraphysiological doses of thyroxine (T4) on bone metabolism in SHAM and OVX young adult rats. Female Sprague Dawley rats (220 +/- 2 g, approx. 5 months of age) were divided into four groups of eight animals each. The animals were intraperitoneally injected 6 days per week with vehicle (Vh): 0.001 N NaOH/0.9% NaCl (SHAM+Vh and OVX+Vh) or 250 microg of thyroxine/kg/day (SHAM+T4 and OVX+T4) during a 5-week period. Serum T4 and osteocalcin (BGP), urinary pyridinolines (Pyr), and creatinine (creat) were determined. At the beginning and at end of the experiment, skeletal bone mineral content (BMC), bone mineral density (BMD), and area (A) of the total skeleton, femur, spine, and whole tibia, as well as proximal, middle, and distal areas of the tibia were assessed by dual X-ray absorptiometry (DXA) in an ultra-high-resolution mode. T4 treatment of the SHAM rats did not induce significant changes in BGP level or Pyr/creat excretion compared with the SHAM+Vh control group. However, these two biochemical bone markers significantly increased due to T4 treatment in OVX rats compared with both OVX+Vh and SHAM+T4 groups (P < 0.05 and P < 0.001, respectively). The OVX+T4 group had a significantly lower DeltaBMD than SHAM+T4 rats in all studied regions (P < 0.05) except for the middle tibia region. OVX+T4 groups presented a significantly lower DeltaBMC and DeltaA compared with SHAM+T4 animals (P < 0.001). OVX+T4 rats significantly impaired the DeltaBMD in the femur (P < 0.01), spine (P < 0.05), whole (P < 0.05) and middle (P < 0.05) tibia whereas T4 treatment of SHAM rats only affected, significantly, the whole (P < 0.05) and the proximal tibia region (P < 0.01). T4 treatment affects bone growth in young adult rats. The effect is significantly greater in the estrogen-depleted than in the estrogen-repleted state. The bone site most adversely affected by T4 treatment depends on the estrogen status. The proximal tibia (principally trabecular bone) was the most affected area in estrogen-repleted rats. Conversely, in OVX rats, the middle tibia (principally cortical bone) presented the greatest decrease in bone density.

Reference data of vertebral morphometry by X-ray absorptiometry (MXA) in Argentine women

Anterior, middle, and posterior heights and A/P and M/P ratios were determined from T5 to L4 in 111 normal Caucasian Argentine women from 20 to 70 years of age using dual energy X-ray absorptiometry (DXA) densitometry (Expert XL). Scanning time was less than 1 minute and the semiautomatic analysis requires approximately 5 minutes. The precision error for the measurements ranged from 2.2% to 4.6%. The absolute precision error for heights was 0.6 mm. The vertebral bodies tended to be significantly larger in younger women than older women, especially for anterior and middle heights and the A/P and M/P ratios of the midthoracic vertebrae (T6-T10). There were no significant differences between pre- and postmenopausal women in the lumbar vertebral heights. It does not appear that this was a cohort effect because stature was identical in both age groups, and there was no age difference in posterior height. The Expert-XL software normalized the vertebral height based on the average height of the L2-L4 segment in order to minimize the influence of interindividual variation of body size. The average Z-scores for vertebral heights and ratios provided by the software were close to zero indicating that the normalization procedure appropriately corrected for smaller stature in Argentine women. Consequently, the reference values for morphometry X-ray absorptiometry (MXA) were appropriate for our population. In summary, we found that (1) in "normal" women the anterior heights of the thoracic vertebrae (and therefore the A/P ratio) were higher in premenopausal than in postmenopausal women; and (2) the normalization approach corrected for differences of vertebral height and allowed utilization of the manufacturers software in our population.

Effect of unilateral superior cervical ganglionectomy on bone mineral content and density of rat's mandible

To assess the effect of a local sympathectomy on bone metabolism, the effect of a unilateral superior cervical ganglionectomy (Gx) on growth and bone mineral content and density of the ipsi- and contralateral mandibles was examined in female rats. A significant increase in the hemi-mandibular bone ipsilateral to Gx was found as compared to the contralateral, sham-operated side 30 days, but not 15 days, after surgery. Bone mineral content of the hemi-mandibular bones was significantly lower in the side ipsilateral to Gx in the group of rats killed on the 30th day after surgery. Since no difference in areas between innervated and denervated hemi-mandibles was found, bone mineral density was also significantly lower in the hemi-mandible ipsilateral to Gx. The results further support that a regional sympathectomy causes qualitative alterations in bone modeling and remodeling, leading to bone resorption.

Bone mass changes during pregnancy and lactation in the rat

We examined bone mass changes in the total, axial, and appendicular skeleton as well as in the different subareas of femur and tibia in rats fed on a normal calcium diet. A total of 16 virgin Wistar rats, approximately 5 months of age (270+/-30 g), were assigned to two groups of eight rats each. One group was mated and, for each pregnant rat, a nonpregnant control rat was studied simultaneously. Weaning was performed when the pups reached 38+/-3 g body weight. At the beginning (t = 0), on the first day postpartum (t = 22 days), and at weaning (t = 45 days), total skeleton bone mineral content (BMC), area, and bone mineral density (BMD) were determined by dual-energy X-ray absorptiometry (DXA) in vivo under anesthesia. Body weight increased significantly during pregnancy (p < 0.05) and decreased at weaning, whereas control rats showed a slow, gradual increment without reaching a significant difference. During pregnancy, BMC and area of the total skeleton increased significantly in pregnant rats, but the changes in BMD were not different compared with the control group. A completely different pattern was observed between groups during the 23 days of lactation. While the skeleton continued to grow in the control group (BMC and area increased), the total skeleton of lactating rats showed no change in area (size), small decreases in BMC, and a significant decrease in BMD (p < 0.05). Consequently, although BMC and BMD of both groups were similar at the time of delivery, BMC was 12.0% lower and BMD 4.9% lower at the end of lactation in the lactating rats compared with the control group. The contribution of the maternal skeleton to the lactation period was not similar; that is, the areas with the highest trabecular component showed the greater average differences in BMD at the time of weaning (proximal tibia -19.9%, distal femur -12.6%, spine -10.9%) (p < 0.05), compared with relatively minor, nonsignificant losses in areas where cortical bone predominates (distal tibia -5%, middle tibia -5.2%). Our experimental results demonstrated the usefulness of DXA in vivo to visualize changes in BMD during the reproductive cycle of the rat. Moreover, the data confirm that normal pregnancy in the rat appears to exert little influence on bone, whereas lactation induces significant bone loss, mainly in the areas of predominant trabecular bone.

Osteomalacia in a patient with severe anorexia nervosa

A 27-year-old woman with anorexia nervosa since adolescence was referred to our unit for generalized bone pain most severe at the pelvis and an inability to stand. She reported a pelvic fracture diagnosed one year earlier, which had failed to heal. Laboratory tests showed low serum phosphate, normal total serum calcium corrected for serum albumin, and very low urinary calcium excretion. Serum bone alkaline phosphatase and parathyroid hormone levels were elevated, whereas 25-hydroxy-vitamin D was severely decreased. Multiple vertebral and rib fractures were seen on plain radiographs. Radiographic images consistent with osteomalacia were pseudofractures of the left inferior pubic ramus, a bilateral complete fracture of the superior pubic ramus, and a characteristic pseudofracture (Looser zone) in the lateral margin of the right scapula. Vitamin D-deficient osteomalacia with secondary hyperparathyroidism was strongly suspected at this point, but it was decided not to confirm this diagnosis by bone biopsy with histomorphometry and osteoid labeling because of the emotional instability of the patient. Dual-energy X-ray absorptiometry disclosed severe demineralization. After two months on calcium and vitamin D supplements, the bone pain had abated and the patient was able to stand. Serum calcium had increased; serum phosphate, 25-hydroxy-vitamin D, and parathyroid hormone had returned to normal, and the pseudofractures showed evidence of healing. Osteoporosis is a well-known complication of anorexia nervosa. This case shows that osteomalacia can also occur. Vitamin D status should be assessed in patients with long-standing severe anorexia nervosa.

Effect of one year residence in Antarctica on bone mineral metabolism and body composition

OBJECTIVE

To evaluate the changes of the biochemical parameters of mineral metabolism and to assess the effect of these changes on the bone mass of young healthy men who voluntarily lived in the Antarctic Continent for one year.

DESIGN

Lumbar spine and whole body bone mineral density (BMD) were measured pre- and post-campaign (14 months later). Serum and urinary biochemical parameters were measured every two months. Serum levels of calcium, phosphate, total alkaline phosphatase, parathormone (PTH) and 25-hydroxyvitamin D (250HD) were determined in blood fasting samples; and hydroxyproline, calcium and creatinine in 2 h fasting urine. The subjects received a dose of 100 i.u./d of vitamin D during May after obtaining the samples and then an average of 125 i.u./d from July to January.

SUBJECTS

Seventeen healthy volunteers, who left Buenos Aires during the 1992 summer: ten arrived in the Belgrano II Base at the end of January and the other seven arrived in San Martín in March and stayed there up to summer 1993.

RESULTS

BMD increased in lumbar spine (L2-L4), total body and the subarea of the legs but there were no differences between the pre- and post-campaign values in arms and pelvis. The percentage of fat mass decreased significantly after 1 y of residence in Antarctica, in comparison to the basal values. Most biochemical parameters remained unaltered and within the normal range during the whole study. PTH showed a nadir in March (end of the summer) when compared to initial levels (73.0 +/- 28.2 vs 39.9 +/- 32.7 pg/ml, P < 0.05), and recovered its initial value in spring. Calcium levels showed a significant decrease in March (9.5 +/- 0.4 vs 8.5 +/- 1.0 mg%, P < 0.01). 25OHD levels began to decrease in March (24.7 +/- 6.4 vs 18.7 +/- 5.3 ng/ml), reaching a minimum value whose difference approached statistical significance during the winter period (July: 16.4 +/- 8.2 ml, 0.05 < P < 0.06). No significant changes in serum phosphate, total alkaline phosphatase, urinary hydroxyproline/creatinine and calcium/creatinine ratios were found through the year.

CONCLUSIONS

25OHD levels decreased in autumn and winter (nadir in July) and recovered the initial levels by the end of the campaign. An unexplained marked diminution in PTH and serum calcium was found at the beginning of the campaign. In spite of the low vitamin D levels, bone mass in this group of young healthy men increased, probably because of their intense physical activity.

Risk factors for the development of vertebral and total skeleton osteoporosis in patients with primary biliary cirrhosis

The objectives of this work was to (1) study the bone mineral density (BMD) of the lumbar spine, total skeleton, and body composition in patients with primary biliary cirrhosis (PBC) and (2) evaluate the risk factors (premature menopause, stages of the disease, hyperbilirubinemia) and bone and liver biochemical parameters for the development of osteoporosis. We studied 23 women with a compatible diagnosis of PBC. The BMD and body composition were evaluated by X-ray absorptiometry (Lunar DPX-L). The average age of the population was 56.7 +/- 10.2 years. The BMD of the lumbar spine and of the total skeleton was 1.3 SDs below the normal population matched for sex and age. In the total skeleton, the legs were the most severely affected area (Z score -1.5). The body composition showed no significant difference compared with the normal population. The BMD of 56% of the patients was less than -2.5 SDs from the average normal young values. Patients with a history of vertebral fractures had diminished mineral density of the lumbar spine, as did those who had had no fractures. Of the risk factors studied, patients with premature menopause had a lower bone mass compared with patients with normal menopausal age (Z score of the total skeleton was -2.1 +/- 1.8 versus -1.1 +/- 1.0) but the difference did not reach statistical significance. The bone mass was not affected in patients with regular menstrual cycles. There were no statistically significant differences in high levels of bilirubin, advanced stages of the disease, or the biochemical variables studied. It is concluded that patients with primary biliary cirrhosis present diminished cortical and trabecular bone mass, whereas body composition was unaffected. Premature hormone deficit, possibly triggered by the chronic hepatic pathology, is a contributing factor to the osteoporosis in this population.

[Treatment of Paget's disease with olpadronate. Its efficacy in partial responders to oral pamidronate]

Bisphosphonates are the treatment of choice in patients with Paget's disease. However in patients with an extensive disease it has been difficult to achieve complete biochemical remission. We studied the efficacy of the new bisphosphonate: olpadronate (dimethyl APD) in 37 patients (21 men and 16 women) with Paget's disease of (mean +/- 1SD) 68 +/- 8 years of age: Group I: 12 patients without previous specific treatment. Group II: 25 patients who had been treated before (time free of treatment before olpadronate: 11 +/- 8 months). (Table 1). Olpadronate was given orally in doses of 100 to 200 mg/day. Initial dose and/or increment of the dose during treatment were decided accordingly to the biochemical response. The length of therapy was (mean +/- 1SD) 3.5 +/- 2.4 months (range 0.5-13 months) and was adjusted to the changes produced upon the biochemical indexes of bone turnover. Olpadronate was well tolerated by all the patients except for one who discontinued the treatment due to gastrointestinal symptoms. Mean alkaline phosphatase (APh) decreased in both groups of patients as follows: Group I: basal: 36 +/- 20 KAU, final: 12 +/- 3 KAU (normal range: 5 to 15 KA units) and group II: basal 45 +/- 30 KAU final 14 +/- 10 KAU. (Table 2). Normalization of APh was observed in all patients of group I and in 21/25 patients of group II. Three patients of group II had partial responses (60% of diminution of APh without reaching normal values) and treatment was not effective in 1 patient. The length of remission was 8.7 +/- 5.7 months in group I and 10.4 +/- 8.1 months in group II. There was a significant inverse correlation between duration of remission and APh level post treatment. Fourteen patients of group II (7 women and 7 men) had previously received oral pamidronate (APD) in different cycles during a period of 6.6 +/- 4.2 years. After the first APD cycle, only 2 out of 14 achieved normal APh values and none of the 14 achieved complete biochemical remission after the last APD cycle. Olpadronate caused a significant decrease of serum APh and THP compared to the lowest values observed during APD treatment. Normalization of APh was observed in 12/14 of these partial responders to APD. (Table 3 and Figure 1). In conclusion, oral Olpadronate in a dose of 100 to 200 mg was well tolerated and effective in the treatment of Paget's disease even in those previous partial responders to APD.

Bone mineral density and bone size in men with primary osteoporosis and vertebral fractures

The bone mineral density (BMD) at the lumbar spine, proximal femur, and total skeleton was evaluated in 38 men with primary osteoporosis and vertebral fractures. BMD of the patients was significantly reduced over all skeletal areas compared with controls. The Z-score of the lumbar spine (-2.8 +/- 0.9) was less than that of the other areas (P < 0.001) except the legs (-2.5 +/- 1.1) (p.n.s.) showing that bone loss had a tendency to be greater over the axial skeleton. Vertebral dimensions compared with age-matched controls were as follows: projected L2-L4 area (cm 2): 45.7 +/- 5.6 versus 53.7 +/- 3. 6 (P < 0.001); vertebral width (cm): 4.37 +/- 0.44 versus 4.90 +/- 0. 36 (P < 0.001). Serum biochemical parameters and testosterone levels were similar between osteoporotic and control men. We conclude that men with vertebral osteoporotic fractures have reduced vertebral BMD and vertebral dimensions compared with age-matched controls. Thus, these findings indicate that the achievement of a reduced bone size at the end of the growth period or a failure of periosteal increase during adult life is likely to contribute to the pathogenesis of the vertebral fractures observed in older men.

The effect of olpadronate in ovariectomized thyroxine-treated rats

Hyperthyroidism increases bone turnover and induces bone loss. This study examines the effect of thyroid hormone excess on two biochemical markers of bone turnover (hydroxyproline and bone alkaline phosphatase) as well as on bone mineral content (BMC) and bone mineral density (BMD). The possible protective role of dimethyl-APD (olpadronate, OLP), on both suppression of bone turnover and bone mineral loss in ovariectomized (ovx) rats, was also studied. Female Sprague-Dawley rats, were assigned to five groups of eight rats each: sham, ovx, ovx OLP treated (0.3 mg/kg per week), ovx T4 treated (250 micrograms/kg per day), and ovx T4-OLP rats. Rats were killed after 5 weeks of treatment. At the end of the study, blood samples were analyzed for serum calcium, phosphorus, T4, total and bone alkaline phosphatase (ALP and b-ALP), and urinary samples for hydroxyproline/creatinine ratio (HOProl/creat). Moreover, total BMC, BMD, and scanned area were determined by DXA. Ovx T4-OLP-treated rats presented higher values of b-ALP than ovx T4-treated, ovx, and sham rats (p < 0.05). Ovx increased HOProl/creat excretion compared with sham (p < 0.05), but it was similar compared with ovx T4-treated rats. OLP treatment reduced HOProl/creat excretion in both ovx T4-treated (p < 0.05) and ovx rats (p < 0.05). The final BMC in ovx was lower than in the sham group, but the difference was not statistically significant (p < 0.08). The lowest BMC was observed in ovx T4 rats (p < 0.05). When final BMC was expressed per body weight (BMC/W), ovx rats presented a significantly lower BMC/W than sham rats (p < 0.05). Ovx OLP rats had BMC/W levels higher than ovx (p < 0.005), ovx T4 (p < 0.01), and ovx T4-OLP rats (p < 0.01). The ovx group had a final BMD lower than sham animals (p < 0.05), but not significantly different than the ovx T4 rats. BMC and BMD of OLP ovx rats, whether they received T4 or not, was similar to the sham group. The highest final BMD was observed in the ovx T4-OLP group. In summary, the prevention of an increase in HOProl excretion accompanied by the fact that final BMD and BMC in OLP-treated animals were comparable to sham control rats may reflect that OLP administration could inhibit bone resorption in both T4-treated or -untreated rats. Although further studies are necessary, these findings may have clinical relevance in estrogen-depleted patients to whom medical management other than the reduction of T4 administration would be desirable.

Longitudinal study on the effect of treatment on body composition and anthropometry of celiac disease patients

OBJECTIVES

This prospective study was designed to assess the nutritional changes associated with the long-term treatment of celiac disease. In addition, we analyzed whether these changes were related to the degree of compliance with a gluten-free diet.

METHODS

We studied nutritional parameters and body composition in 25 newly diagnosed celiac patients after a mean period of 37 months (range 25-49 months) on a gluten-free diet. Body composition parameters (fat, lean tissue, and bone masses) were measured by dual energy x-ray absorptiometry. Anthropometry was measured according to conventional formulas.

RESULTS

At diagnosis, fat (-49%), lean tissue (-12%), and bone (-24%) compartments were reduced, compared with that of sex- and age-matched controls. After treatment, we noted a significant increase in body weight (p < 0.0001), fat mass (p < 0.0005), bone mass (p < 0.002), and body mass index (p < 0.005). In contrast, we did not observe a significant increase in lean-tissue mass or muscle mass. Patients who adhered strictly to a gluten-free diet experienced a greater, though nonsignificant improvement in fat mass, body weight, and body mass index than patients whose compliance had been partial. Mean caloric intake at the end of the study was significantly lower among those patients who had adhered strictly to a gluten-free diet, compared with those who had complied only partially with the diet (p < 0.05).

CONCLUSIONS

This study shows that the institution of a gluten-free diet in celiac disease patients results in a significant improvement in nutritional parameters, as measured by anthropometry and/or body composition. This effect was more pronounced in patients who followed strict gluten restriction and was related mainly to changes in fat and bone compartments.

Long-term effect of gluten restriction on bone mineral density of patients with coeliac disease

AIM

To assess the long-term effect of a gluten-free diet on bone mineral density of adults with untreated coeliac disease.

METHODS

Bone mineral density was assessed at baseline and after a mean duration of 37 months of treatment in 25 unselected newly diagnosed coeliac patients.

RESULTS

At baseline, osteopenia (> -1 s.d. below normal) was evident in the lumbar spine and total skeleton in 18 (72%) and 21 (84%) patients, respectively. At the end of the study, bone density had increased (mean bone mass Z-score increase: Z-score +1.0 for the lumbar spine and +1.1 for total skeleton) in 22 and 23 patients, respectively. Patients who adhered to strict gluten restriction (n = 15) demonstrated a similar bone remineralization in the spine than those patients with partial compliance (n = 10) (mean Z-score increase: +1.0, in both areas). A greater mean annual change in Z-score in the total skeleton was noted in patients who followed strict gluten restriction (0.4 +/- 0.1) respect to those with partial compliance (0.3 +/- 0.1); however, this difference was not statistically significant. Pre-menopausal women had significantly greater remineralization that post-menopausals (P > 0.05). Remineralization showed an inverse correlation with the degree of basal osteopenia (r = -0.525; P < 0.002).

CONCLUSIONS

Long-term treatment with gluten-free diet produces a significant improvement in bone density in coeliac patients. Remineralization was more pronounced in patients who better comply with gluten-free diet, in pre-menopausal women and in patients with the lowest baseline bone mineral density.

Effect of treatment on bone mass, mineral metabolism, and body composition in untreated celiac disease patients

BACKGROUND/AIMS

Osteopenia is a common complication of celiac disease. The aims of this study were to evaluate whether treatment produces bone remineralization and whether calcium and vitamin D supplementation are necessary to reduce osteopenia.

METHODS

Bone mineral density and biochemical parameters of bone and mineral metabolism were measured in 14 newly diagnosed adult celiac disease patients. All patients were treated with a gluten-free diet and were randomized to receive diet only (n = 7) or diet plus calcium (1.0 g/day) and vitamin D (32,000 IU/wk) supplementation (n = 7). Bone density was measured at baseline and at 6 and 12 months of follow-up. Tests for biochemical determinations were repeated every 3 months.

RESULTS

At diagnosis, 11 patients had evidence of osteopenia (> 1 SD below normality) in the spine and total skeleton. After 12 months of gluten restriction, overall bone mass had increased 5.0% (p < 0.01) in the lumbar spine and 5.0% (p < 0.002) in the total skeleton. When one only considers those 11 patients who strictly followed gluten restriction, bone density increased 8.4% in the lumbar spine and 7.7% in the total skeleton. Remineralization occurred throughout the skeleton but was more pronounced in the axial than in the peripheral skeleton. The increase in bone mass was independent of age or menopause. Remineralization in patients treated with diet only was similar to that of patients treated with diet and supplements. Basal biochemical parameters showed a high bone turnover with secondary hyperparathyroidism. Treatment induced a decrease in bone turnover activity. However, a complete restoration of biochemical parameters was not achieved.

CONCLUSIONS

Strict gluten avoidance promoted a significant increase in bone mineral density. However, values still remain markedly low after 1 yr in several patients. Although calcium and vitamin D supplementation did not provide additional benefit to that obtained by diet alone in the doses administered, our results do not preclude a possible effect of vitamin D at higher dose.

Vitamin D prophylaxis in children with a single dose of 150000 IU of vitamin D

OBJECTIVE

To determine the efficacy of a single oral dose of 150,000 IU of vitamin D2 at the beginning of autumn for preventing winter vitamin D deficiency in children in Ushuaia (55 degrees S).

DESIGN

The study was prospective.

SUBJECTS

79 children clinically healthy with 8.6 +/- 1.4 y of age (X +/- s.d.).

INTERVENTIONS

Fasting serum venous samples and 2 h urine samples were obtained immediately before and 6 w and 5 mon after the vitamin D dose. Parents informed consent was obtained previous to the study. In a subgroup of 30 children serum levels of calcium (sCa), phosphorus (sP), total alkaline phosphatase (TAP), 25 hydroxyvitamin D (25 OHD), parathyroid hormone (PTH) and the urine calcium/creatinine ratio in a 2 h urine sample (UCa/UCreat) were measured. In the whole group sCa and the ratio uCa/ucreat were measured.

RESULTS

After 150,000 IU of vitamin D2 administration, serum 25 OHD levels at the end of winter (17.0 +/- 9.4 ng/ml) were similar to those at the beginning of autumn (18.7 +/- 10.7 ng/ml), but significantly higher from those obtained in a previous study without vitamin D (9.8 +/- 3.8 ng/ml, P < 0.001). PTH levels were higher at the end of winter (P < 0.02), but this augmentation was lower than the increment observed without vitamin D. Plasma calcium levels and the urine calcium/creatinine ratio were lower at 5 months after vitamin D2 dose (P < 0.02 and P < 0.05 respectively). In the total group the serum calcium was lower after the fifth month (P < 0.05). The Uca/Ucreat ratio was lower at 6 w and 5 mon (P < 0.05 and P < 0.001).

CONCLUSION

A single dose of 150,000 IU of vitamin D maintained appropriate levels of 25 OHD without inducing hypercalcemia nor hypercalciuria, but a winter increment of PTH (smaller than in the group without vitamin D) was not inhibited.

Regression of calcinosis during diltiazem treatment in juvenile dermatomyositis

An 8-year-old girl with juvenile dermatomyositis (DM) developed dystrophic calcifications 26 months after diagnosis. She also had severe steroid induced bone loss (osteoporosis). The calcifications turned into generalized heterotopic calcinosis with an exoskeleton-like pattern, despite successful treatment of her myopathy with methylprednisolone and immunosuppressive drugs. She was subsequently treated with oral diltiazem (5 mg/kg/day) to control calcinosis and oral pamidronate (4 mg/kg/day) in addition to calcium and vitamin D supplementation, which she had been taking for 3 years. After 21 months of treatment, clinical and radiological examination revealed dramatic regression of the calcinosis. Bone mass reached normal levels, as determined by bone absorptiometry. Diltiazem alone or in combination with other drugs could be a useful therapy in patients with juvenile DM and pronounced calcifications.

Early changes of body composition in asymptomatic celiac disease patients

BACKGROUND/AIM

This is a study of patients with asymptomatic celiac disease. The aims of this study were: 1) To evaluate the nutritional status of asymptomatic patients with newly diagnosed celiac disease, and 2) to compare these findings with those of untreated/symptomatic and treated patients.

MATERIAL

We examined 41 patients with celiac disease divided into three groups: a) 8 asymptomatic (diagnosed in a study of first-degree relatives of probands), b) 20 untreated/symptomatic patients, and c) 13 treated patients. Nutrition of patients from groups A and B was assessed at the time of diagnosis.

METHODS

Nutritional status was evaluated by: 1) body composition (fat and lean mass) by dual energy x-ray absorptiometry (DEXA), and 2) anthropometric measurements.

RESULTS

Compared with sex and age matched controls (n = 153), asymptomatic patients presented a moderate but significant reduction of the fat compartment (-29%; p < 0.001), but not of the lean-tissue mass (p = NS). Untreated/symptomatic patients showed a more severe depletion of fat (-46%; p < 0.001) and lean mass (-9.0%; p < 0.05) compared with healthy controls. Although fat mass of treated patients was significantly reduced with respect to controls (-24%; p < 0.003), lean mass was not affected. The anthropometric measurements of fat showed a significant correlation with the evaluation by DEXA (multiple regression analysis r = 0.918).

CONCLUSION

Asymptomatic patients in our study with an unequivocal diagnosis of celiac disease established by mucosal biopsy exhibited a modified body composition.

Hormone replacement therapy increases trabecular and cortical bone density in osteoporotic women

Twenty five postmenopausal Caucasian women with established osteoporosis or severe osteopenia were treated with continuous combined estrogen/progesterone (2 mg 17 beta estradiol and 5 mg medroxiprogesterone) and 1000 mg of calcium daily. The mean age of the patients was 57 +/- 6 years (range 44 to 69 years), and the average postmenopausal interval was of 10.7 +/- 4.2 years. The bone mineral density (BMD) of the lumbar spine and proximal femur was determined using DXA densitometer at baseline, 12 and 24 months of treatment. Serum and urine measurements were done at baseline and 12 months. After 24 months of treatment bone mineral density increased at the trochanter 10.2% p < 0.001, lumbar spine 9.6% p < 0.001, Ward's triangle 8.6% p < 0.005 and femoral neck 5.7% p < 0.001 in comparison to basal levels. In the first year of treatment serum alkaline phosphatase and urinary hydroxiproline diminished significantly in comparison to basal levels (p < 0.001, for both). In conclusion, this study indicates that continuous combined estrogen progesterone therapy decreases bone turnover and increases BMD of the spine, femoral neck and trochanter in established osteoporosis.

Bone mineral density in a native population of Argentina with low calcium intake

OBJECTIVE

To determine the bone mineral density (BMD) of a group of natives from Tafi del Valle, Argentina, to examine possible differences compared to other populations.

METHODS

BMD of lumbar spine and proximal femur was evaluated by dual x-ray absorptiometry (DEXA), in volunteer natives of El Potrerillo y El Rincon (descendants of the Amaichas and Quilmes). Forty-seven women and 31 men between 20 and 80 years of age were assessed. Average daily intake of calcium, physical activity level, serum levels of 25-OH vitamin D (25-OH-D), calcium, phosphorus and alkaline phosphatase were also determined.

RESULTS

Average calcium intake was 345 +/- 22.4 mg/day (mean +/- SD). The average sunlight exposure was 3.8 +/- 0.44 h. Degree of physical activity was moderate/hard (grade 4) to very hard (grade 6) in those 60 yrs of age or younger. Laboratory values were normal except for 25-OH-D levels, which were significantly greater in Tafi del Valle (26.8 ng/ml) than in Buenos Aires (20.7 ng/ml); (p < 0.05) BMD of the proximal femur of both sexes was significantly greater compared to the reference groups; Z score of the female population was femoral neck: +/- 0.64 (p < 0.05); Ward's triangle: +/- 0.64 (p < 0.001); trochanter: +/- 0.90 (p < 0.001). Among men, femoral neck: +/- 0.53 (p < 0.01); Ward's triangle: +/- 1.45 (p < 0.001); trochanter: +/- 0.95 (p < 0.001). No significant differences were observed in the lumbar spine BMD. The high physical activity required by the mountainous land of Tafi del Valle may be the cause of increased BMD at the proximal femur among these people. High values of vitamin D produced by increased sun exposure can lead to greater absorption of calcium despite low calcium intake.

CONCLUSION

Greater physical activity, higher levels of vitamin D, and racial factors in the native population could explain the greater BMD seen in the proximal femur despite low calcium intake.

Ultrasound and dual X-ray absorptiometry densitometry in women with hip fracture

To assess the usefulness of the measurement of the os calcis by ultrasound, a method that probably reflects bone quality as well as density, we have studied 54 women with hip fracture of the proximal femur and a control group. Ultrasound evaluation of the os calcis [broadband ultrasound attenuation (BUA), speed of the sound (SOS), and a combined index ("stiffness")], and bone mineral density (BMD) determination over the proximal femur by dual X-ray absorptiometry (DXA) were performed. Weight, BMD, and ultrasound values in the hip fracture patients were significantly lower than controls (P < 0.001). The Z-scores for BUA and stiffness were not different than that for femoral neck, Ward's triangle or trochanteric BMD (between -1.7 and -1.5). The odds ratios determined by receiver-operating characteristics (ROC) analysis were greater at the femoral neck (25.1) and BUA (24.4). Intermediate values were found at stiffness (16.9), Ward's triangle (12.8), and trochanter (11.1), and lower values were obtained at SOS (4.2). In turn, patients with trochanteric hip fractures had a significantly lower femoral neck and Ward's triangle BMD, stiffness, and BUA than patients with cervical hip fractures. Comparing a subgroup of 30 women with hip fractures without vertebral fractures with an age-matched group of 87 women with osteoporotic vertebral fractures, both groups were of similar weight and BMD but all ultrasound values were significantly lower in the hip fractures compared with vertebral fracture patients (P < 0.05 - P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Discrimination of total body bone mineral density measured by dexa in vertebral osteoporosis

The assessment of bone mineral density (BMD) is the usual study to detect patients at risk for developing osteoporosis. The aim of this study was to compare the discriminative ability of total body BMD and its different subregions with the more usual measurements of BMD of the lumbar spine and femoral neck in women with osteoporotic fractures of the spine. The BMD was determined in 61 osteoporotic (at least one vertebral wedge fracture visible in the lateral X-ray film of the thoracic or lumbar spine) and 61 age-matched control women. Measurements were made by dual X-ray absortiometry (DXA) with a total body scanner. The BMD of the osteoporotic women was significantly lower at all skeletal areas compared with control (P < 0.001). The diminution was less pronounced but still significant at the arms (P < 0.05). The areas with the largest Z score in the osteoporotic group were antero-posterior lumbar spine (-1.78), femoral neck (-1.71), legs (-1.67), and total body (-1.59). There was no significant difference among the Z scores of the four above-mentioned measurements. The Z score of the arms (-0.79), spine (-1.12), and head (-1.29) were significantly lower than the Z score of the total body. The Z score of the pelvis was lower than the Z score of the total body but the difference only approached statistical significance (0.05 > P < 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Solar ultraviolet B radiation and photoproduction of vitamin D3 in central and southern areas of Argentina

The incidence of nutritional rickets in the southern part of Argentina is 8-12 times higher than in the rest of the country. Winter 25(OH)D serum levels in normal population of southern areas are lower than in central and northern areas. To elucidate these differences, we compared the photoconversion of provitamin D3 (7-DHC) to previtamin D3 in two cities: Ushuaia (latitude 55 degrees S) and Buenos Aires (34 degrees S). Ampules containing 7-DHC were exposed to sunlight one day in the middle of each month either from 10:30 a.m. to 2:30 p.m. or from 8:00 a.m. to 5:00 p.m. The percentages of photoproducts formed were determined by high performance liquid chromatography (HPLC). Previous studies have proved that this is a valid model to assess "in vitro" the photoproduction of vitamin D3 in human skin. Previtamin D3 + vitamin D3 formed in Ushuaia were less (p < 0.02) than those found in Buenos Aires during all seasons: summer, (X +/- SEM) 6.4 +/- 0.8% vs. 13.2 +/- 1.8%; autumn, 1.2 +/- 0.7% vs. 6.3 +/- 1.3%; winter, 0.8 +/- 0.7% vs. 3.6 +/- 0.7%; spring, 3.4 +/- 0.5% vs. 9.1 +/- 1.1%. The photoproducts produced from 10:30 a.m. to 2:30 p.m. were similar for each month and latitude to those formed when the ampules were exposed from 8:00 a.m. to 5:00 p.m. We conclude that in Ushuaia there is a prolonged "vitamin D winter" during which cutaneous synthesis of vitamin D is absent, leading to lower serum values of 25(OH)D and contributing to the higher incidence of rickets.

Body composition and bone mineral density in untreated and treated patients with celiac disease

Body composition and bone mineral density (BMD) were studied by X-ray absorptiometry in 20 untreated and 12 treated women with celiac disease, as well as in 85 age-matched control women. Untreated patients had a significantly lower body weight, fat mass, lean tissue mass and BMD at the lumbar spine and total skeleton compared to controls (p < 0.001 for all parameters). Treated patients had also a significantly lower body weight (p < 0.01) fat mass (p < 0.05) and bone mineral density at lumbar spine and total skeleton (p < 0.05) compared with controls, but lean tissue mass was not diminished. However, treated patients had a significantly higher body weight, fat mass and BMD of the total skeleton compared with untreated celiac patients (p < 0.01 for all parameters). Serum alkaline phosphatase levels were increased in untreated patients but serum 250HD was normal. In conclusion, celiac disease causes a global and almost universal reduction of fat mass and BMD. The results of this cross-sectional study suggest that osteopenia does not seem to be completely restored by adequate treatment. Alteration of vitamin D metabolism was not the cause of osteopenia in the majority of patients.

Bone mineral affection in asymptomatic adult patients with celiac disease

OBJECTIVES

Osteopenia is a well-known complication of overt celiac disease, but whether such defective bone mineralization is present among asymptomatic or silent patients is not known. Our objectives were: 1) to examine bone mineralization of a group of asymptomatic celiac patients; 2) to compare these results with those of symptomatic patients.

METHODS

Bone mineral density of the spine and total skeleton by dual energy x-ray absorptiometry and serum parameters of mineral metabolism of eight recently diagnosed asymptomatic patients with celiac disease were studied. Results were compared with those obtained in 20 untreated symptomatic celiacs, 14 patients treated with gluten-free diet for a mean time of 15 yr, and 153 healthy adult subjects, matched by sex and age.

RESULTS

Four and five out of eight asymptomatic patients presented with reduced mineralization of the spine and the total skeleton, respectively (> 1 SD below normal values for sex and age). Two patients presented with severe osteopenia of the spine, and the other three presented with severe osteopenia of the whole skeleton (> 2 SD below mean normal values). Osteopenia at plane bone level (total skeleton) was significantly lower when compared to healthy controls (p < 0.02). Symptomatic untreated patients had significantly more severe deterioration of bone mineralization than did asymptomatics (p < 0.05) and treated patients (p < 0.05). No difference in bone mineral density was observed between treated patients and asymptomatic celiacs. Serum levels of calcium, alkaline phosphatase, 25-OH vitamin D, and parathormone did not show conclusive abnormalities.

CONCLUSIONS

Our findings provide direct evidence that reduced bone mineralization occurs in asymptomatic celiac patients before any other symptom becomes evident. Only early diagnosis and treatment of celiac disease can avoid the deterioration of the bone structure observed in all clinical status of celiac disease.

Epidemiology of hip fractures in an urban population of central Argentina

The epidemiology of fractures of the proximal femur was studied over a 1-year period in the city of La Plata, Argentina (population 288,000, latitude 35 degrees S). One hundred and ninety-five patients (164 women and 31 men) aged 50 years or over suffered a fracture of the proximal femur. The median age was 80 years in women and 77 years in men. The incidence of hip fractures per 100,000 inhabitants aged 50 years or over was 379.4 in women and 100.9 in men (female/male ratio 3.76). The age-adjusted ratio was 2.90. In women the incidence increased from 11.3 in the sixth to 2807.3 in the ninth decade.

Age dependence of the normal/abnormal difference of bone mineral density in osteoporotic women

Bone mineral density (BMD) is the major factor in bone strength and in the risk of suffering osteoporotic fractures. The aim of this study was to examine the normal/abnormal difference for antero-posterior (AP) spine, lateral spine, proximal femur and total body BMD to assess if age influences discrimination at three different decades between 50 and 80 years of age. The BMD was determined in 61 control women and 60 osteoporotic women (at least one vertebral wedge fracture readily visible in the lateral X-rays of the thoracic or lumbar spine). Measurements were made by DEXA with a total body scanner. The BMD of the whole group of osteoporotic women was markedly lower than that of age-matched controls at all skeletal areas (P < 0.001) except at the arms where the difference was smaller (P < 0.02). The Z-score (the difference between osteoporotic patients and age-matched control divided by the intrapopulation S.D.) was similar (approximately -1.7) over the AP spine, femoral neck, Ward's triangle, total body and legs. It was significantly lower at the arms (-0.8, P < 0.001), lateral spine (-1.4, P < 0.01) and trochanter (-1.3, P < 0.001) compared with the Z-score of the AP spine. The analysis of the results by decades of age disclosed that the higher Z-score on the 6th and 7th decades corresponded to the AP lumbar spine (approximately -2.0). A high descrimination was also observed for the femoral neck, Ward's triangle and legs while the Z-score of the lateral lumbar spine, total body, trochanter and arms were significantly lower than that of the AP lumbar spine. However on the 8th decade the Z-score of the AP lumbar spine diminished to -1.2 and was only significantly higher than the Z-score of the arms (P < 0.01). The study showed that, in women 50-60 years of age--the period where the majority of studies are made for prevention of osteoporosis, none of the other skeletal areas were superior to the AP spine in discrimination for spinal osteoporosis. Proximal femur and legs densitometry gave lower but not significantly different Z-score than the AP spine, while the remaining areas were significantly inferior to AP spine in separating osteoporotic and normal women.

Serum levels of 25-hydroxyvitamin D in a year of residence on the Antarctic continent

OBJECTIVE

Since exposure to sunlight is the main source of vitamin D in human beings and skin photosynthesis decreases markedly as the latitude increases, we studied the changes in serum 25-hydroxyvitamin D (25(OH)D) levels in young healthy men who lived in the Antarctic Continent during 1 year.

DESIGN

Blood was drawn in the fasting state every 2 months from March 1990 to January 1991 to determine the serum levels of calcium, alkaline phosphatase and 25(OH)D.

SUBJECTS

19 healthy volunteers, who left Buenos Aires (34 degrees S) during the 1990 summer, arriving at the Antarctic bases at the end of January (Belgrano) and in mid-March (San Martín) and stayed there up to summer 1991.

RESULTS

Serum calcium did not change significantly throughout the year. Serum alkaline phosphatase levels were not different comparing the beginning to the end of the year, but autumn and winter levels were lower (P < 0.05). At Belgrano Base the serum 25(OH)D levels (ng/ml) decreased from (mean +/- SD) 18.7 +/- 7.4 (March) to 10.0 +/- 4.3 (July) (P < 0.005) and did not recover for the rest of the year. At San Martín Base the serum 25(OH)D levels descended from 22.0 +/- 5.4 in March to 12.2 +/- 3.7 in August (P < 0.02) and did not increase even at the beginning of summer (January) except in two men with frequent outdoor activities.

CONCLUSIONS

The levels of 25(OH)D of healthy men living in the Antarctic continent decreased to approximately 46% of the initial values and did not increase even at the onset of summer. Further studies should determine the effect of these changes upon calcium-regulating hormones and bone metabolism.

Normalization of spine densitometry

We investigated several transformations of bone mineral content (BMC) and area density (BMD), in particular volumetric density (BMAD), to ascertain the influence on (1) body size dependence, (2) diagnostic sensitivity, and (3) precision. These transformations were examined in a group of 657 normal postmenopausal women and 327 women with osteoporotic fracture. First, expression of results as BMAD removed some of the slight dependence on body size; 21% of the variation in BMC and 15% of the variation i BMD were associated with body weight, but only 8% with BMAD. Second, the Z scores compared with those for age-matched controls for BMD and BMC were -1.85 and -1.71, respectively; the Z score for BMAD was -1.64. Third, the precision error for BMC was reduced by expressing results as BMD (1.1 versus 0.5%); BMAD degraded precision slightly (0.7%). BMD appeared to be the optimal expression for bone densitometry because it provided the best diagnostic sensitivity and lowest precision error; there was a minimal influence of body size on BMD results. This study also showed that osteoporotic women, even in the first postmenopausal decade, had low spine BMD, small vertebral area, and low body weight. Such women may be particularly at risk of crush fracture.