Évolution du nombre de passages aux urgences pour intoxications aiguës lors des périodes de confinement de Covid-19 en Bourgogne-Franche-Comté

Objectif : Estimer l’évolution du nombre de passages aux urgences pour intoxications aiguës (IA) lors des périodes de confinement en 2020 par rapport à l’année précédente.

Matériels et méthode : Une étude rétrospective multicentrique de type transversale a été menée en utilisant les données des résumés de passages aux urgences. Deux périodes ont été étudiées en 2020 : période 1 = 1er confinement et période 2 = 2e confinement et ont été comparées aux mêmes périodes en 2019. Les diagnostics pour IA volontaires ou accidentelles toutes causes ont été définis à partir du code CIM-10. Le critère de jugement principal a été la variation du nombre de passages aux urgences pour IA entre les périodes de confinement en 2020 et les périodes de référence en 2019.

Résultats : Comparé à la même période en 2019, le nombre de passages aux urgences pour IA a baissé de 31 % (p = 0,001) pendant le premier confinement et de 18 % (p = 0,07) pendant le deuxième confinement. Le nombre de passages pour IA médicamenteuse a baissé de 3 % (p = 0,035) pendant le deuxième confinement en comparaison à 2019. Les caractéristiques des patients consultant pour IA étaient comparables dans chacune des périodes.

Conclusion : Dans cette étude, une diminution du nombre de passages aux urgences pour IA a été observée pendant les périodes de confinement en 2020 par rapport aux mêmes périodes l’année précédente.

Thermogenesis induced by five different intravenous glucose/insulin infusions in healthy young men

The thermogenic response induced by glucose/insulin administered intravenously was examined in 22 healthy male volunteers using indirect calorimetry in combination with the euglycaemic insulin clamp technique. Five increasing steady state levels of insulinaemia (62 muU/ml to 1132 muU/ml) were achieved by means of continuous infusions of insulin at 5 rates ranging from 0.5 mU/kg.min to 10 mU/kg.min. Euglycaemia was maintained at each insulin level by infusing glucose at different rates ranging from steady state values of 0.41 g/min to 0.77 g/min. These glucose/insulin infusions resulted in a significant net rise in resting energy expenditure from 0.33 kJ/min to 0.94 kJ/min over preinfusion baseline values for the lowest and the highest doses respectively. There was a highly significant relationship (r = 0.93, p<0.001, n = 42) between the amount of glucose infused and the net increase in energy expenditure over preinfusion baseline values. Intravenous glucose induced thermogenesis (GIT(iv)) was calculated as incremental values of energy expenditure related to step changes in glucose infusion rates. GIT(iv) was found to be approximately 5.5% a physiological plasma insulin levels (i.e. below 200 muU/ml) whereas at supraphysiological levels (i.e.>400 muU/ml) GIT(iv) was increased up to 8%. It was concluded that: 1. the magnitude of the GIT(iv) at physiological insulinaemia was similar to that found by other investigators who have administered glucose per os; 2. the elevated thermogenesis observed at high doses of glucose/insulin infusion is consistent with recent clinical findings showing a markedly increased energy expenditure in patients supported by large quantities of intravenous glucose (TPN).

Long term effects of a single dose of intravenous Ibandronate

For defining the optimal regimen of a treatment of osteoporosis with an intravenous bisphosphonate one needs to know the duration of action of a single dose of the given drug. This allows us to establish the frequency by which a given dose has to be administered for obtaining a sufficient suppression of bone resorption over a longer period. In this study 1 and 2 mg Ibandronate were given as a single i.v. injection to young normal men and to healthy postmenopausal women on a free diet and with no treatment or supplements, and the markers of bone metabolism, as well as BMD, were followed for 6 months. Urinary C-telopeptides decreased by 81-95% 1 week after the injection and remained significantly decreased for 2 weeks after 1 mg Ibandronate, and for 4 months after 2 mg. In men, PTH increased by 80% at one week and remained significantly increased for 2 weeks, after 1mg and 2 mg Ibandronate. Plasma osteocalcin decreased slowly over 2 months in all 3 groups by 22%. Alkaline phosphatase showed similar, but not significant changes. In conclusion, the inhibition of bone resorption induced by 1 mg Ibandronate i.v. does not exceed 1 month and does not allow 3 month intervals in the treatment of osteoporosis, while 2 mg cover 3 months at least.

Intravenous pamidronate as treatment for osteoporosis after heart transplantation: a prospective study

Fractures due to osteoporosis are one of the major complications after heart transplantation, occurring mostly during the first 6 months after the graft, with an incidence ranging from 18% to 50% for vertebral fractures. Bone mineral density (BMD) decreases dramatically following the graft, at trabecular sites as well as cortical sites. This is explained by the relatively high doses of glucocorticoids used during the months following the graft, and by a long-term increase of bone turnover which is probably due to cyclosporine. There is some evidence for a beneficial effect on BMD of antiresorptive treatments after heart transplantation. The aim of this study was to assess prospectively the effect on BMD of a 3-year treatment of quarterly infusions of 60 mg of pamidronate, combined with 1 g calcium and 1000 U vitamin D per day, in osteoporotic heart transplant recipients, and that of a treatment with calcium and vitamin D in heart transplant recipients with no osteoporosis. BMD of the lumbar spine and the femoral neck was measured by dual-energy X-ray absorptiometry in all patients every 6 months for 2 years and after 3 years. Seventeen patients, (1 woman, 16 men) aged 46+/-4 years (mean +/- SEM) received only calcium and vitamin D. A significant decrease in BMD was observed after 6 months following the graft, at the lumbar spine (- 6.6%) as well as at the femoral neck (-7.8%). After 2 years, BMD tended to recover at the lumbar spine, whereas the loss persisted after 3 years at the femoral neck. Eleven patients (1 woman and 10 men) aged 46+/-4 years (mean +/- SEM) started treatment with pamidronate on average 6 months after the graft, because they had osteoporosis of the lumbar spine and/or femoral neck (BMD T-score below -2.5 SD). Over the whole treatment period, a continuous increase in BMD at the lumbar spine was noticed, reaching 18.3% after 3 years (14.3% compared with the BMD at the time of the graft). BMD at the femoral neck was lowered in the first year by -3.4%, but recovered totally after 3 years of treatment. In conclusion, a 3-year study of treatment with pamidronate given every 3 months to patients with existing osteoporosis led to a significant increase in lumbar spine BMD and prevented loss at the femoral neck. However, since some of these patients were treated up to 14 months after the transplant, they may already have passed through the phase of most rapid bone loss. In patients who were not osteoporotic at baseline, treatment with calcium and vitamin D alone was not able to prevent the rapid bone loss that occurs immediately after transplantation.

Serum parathyroid hormone-related protein levels and response to bisphosphonate treatment in hypercalcemia of malignancy

The pathogenesis of hypercalcemia of malignancy comprises increased net bone resorption and enhanced renal tubular reabsorption of calcium (Ca). To evaluate the prevalence of an increased renal tubular reabsorption of Ca index [tubular reabsorption of calcium index (TRCaI)] in cancer patients with hypercalcemia and of elevated circulating levels of PTH-related protein (PTHrP), which is recognized as a major mediator of this syndrome, we investigated 315 well rehydrated patients, aged 58.1 +/- 0.7 yr (mean +/- SEM), with hypercalcemia [albumin-corrected plasma Ca (pCa), >2.7 mmol/L] secondary to histologically proven malignancy. Changes in pCa and, therefore, various Ca filtered loads were obtained by different degrees of bone resorption inhibition achieved with a single infusion of the bisphosphonate ibandronate, given at various doses on a randomized, double blind basis. PTHrP was determined at baseline in 147 of the patients and 7 days after bisphosphonate therapy in 73. Before ibandronate therapy, pCa was 3.36 +/- 0.02 mmol/L, mean TRCaI was increased at 3.09 +/- 0.03 mmol/L glomerular filtration rate (GFR; normal, 2.40-2.90), and 65% of patients had TRCaI above 2.90 mmol/L GFR. Mean serum PTHrP levels were 4.9 +/- 0.5 pmol/L (normal, <2.5) and values above the normal range were found in 53% of the patients (76% in lung and upper respiratory tract malignancies). By 7 days after the infusion of ibandronate, a decrease in pCa of 0.69 +/- 0.03 mmol/L (20.0 +/- 0.7%; P < 0.001) and in bone resorption [mean change in fasting urinary Ca, 0.09 +/- 0.04 mmol/L GFR (47.6 +/- 8.6%; P < 0.001) and 14.4 +/- 1.7 nmol/mmol (27.6 +/- 10.6%; P < 0.01) in deoxypyridinoline] was observed. TRCaI was slightly lowered by 0.30 +/- 0.09 mmol/L GFR. Mean changes in PTHrP, 1,25-dihydroxyvitamin D3, and PTH were +0.7 +/- 0.4 (P = NS), +27.6 +/- 3.0 (P < 0.001), and +2.9 +/- 0.8 (P < 0.005) pmol/L, respectively. After ibandronate treatment, the relative risk of relapsing hypercalcemia was particularly increased (3.43-fold) in lung and upper respiratory tract malignancies. These results obtained in a large cohort of patients indicate a significant prevalence of an increased renal tubular reabsorption of calcium index in hypercalcemia of malignancy and a substantial proportion of patients with detectable PTHrP.

Effect of supplementation with vitamin D3 and calcium on quantitative ultrasound of bone in elderly institutionalized women: a longitudinal study

Supplementation of elderly institutionalized women with vitamin D and calcium decreased hip fractures and increased hip bone mineral density. Quantitative ultrasound (QUS) measurements can be performed in nursing homes, and easily repeated for follow-up. However, the effect of the correction of vitamin D deficiency on QUS parameters is not known. Therefore, 248 institutionalized women aged 62-98 years were included in a 2-year open controlled study. They were randomized into a treated group (n = 124), receiving 440 IU of vitamin D3 combined with 500 mg calcium (1250 mg calcium carbonate, Novartis) twice daily, and a control group (n = 124). One hundred and three women (42%), aged 84.5 +/- 7.5 years, completed the study: 50 in the treated group, 53 in the controls. QUS of the calcaneus, which measures BUA (broadband ultrasound attenuation) and SOS (speed of sound), and biochemical analysis were performed before and after 1 and 2 years of treatment. Only the results of the women with a complete follow-up were taken into account. Both groups had low initial mean serum 25-hydroxyvitamin D levels (11.9 +/- 1.2 and 11.7 +/- 1.2 micrograms/l; normal range 6.4-40.2 micrograms/l) and normal mean serum parathyroid hormone (PTH) levels (43.1 +/- 3.2 and 44.6 +/- 3.5 ng/l; normal range 10-70 ng/l, normal mean 31.8 +/- 2.3 ng/l). The treatment led to a correction of the metabolic disturbances, with an increase in 25-hydroxyvitamin D by 123% (p < 0.01) and a decrease in PTH by 18% (p < 0.05) and of alkaline phosphatase by 15% (p < 0.01). In the controls there was a worsening of the hypovitaminosis D, with a decrease of 25-hydroxyvitamin D by 51% (p < 0.01) and an increase in PTH by 51% (p < 0.01), while the serum calcium level decreased by only 2% (p < 0.01). After 2 years of treatment BUA increased significantly by 1.6% in the treated group (p < 0.05), and decreased by 2.3% in the controls (p < 0.01). Therefore, the difference in BUA between the treated subjects and the controls (3.9%) was significant after 2 years (p < 0.01). However, SOS decreased by the same amount in both groups (approximately 0.5%). In conclusion, BUA, but not SOS, reflected the positive effect on bone of supplementation with calcium and vitamin D3 in a population of elderly institutionalized women.

A 3-year study of prevention of postmenopausal bone loss: conjugated equine estrogens plus medroxyprogesterone acetate versus tibolone

The aim of this study was to investigate the effects of tibolone in the prevention of postmenopausal bone loss over 3 years, and to compare these with the effects of sequential hormone replacement therapy. Forty early postmenopausal women were randomized to a 21-day regimen of conjugated equine estrogens (CEE, Premarin) plus sequential medroxyprogesterone acetate (MPA, Prodafem), or tibolone (Livial) daily. In total, 36 women completed 12 months and were considered for the intent-to-treat analysis, 34 completed 24 months and 23 completed 36 months. Main drop-out reasons were: lost to follow-up (n = 9) and minor side-effects (n = 4). Bone mineral density was measured at baseline and after 6, 12, 24 and 36 months, using dual-energy X-ray absorptiometry at the lumbar spine and the upper femur (neck, trochanter, total hip). In both groups, bone loss was prevented. Treatment with tibolone demonstrated significant increases in bone density at the spine (+4.6%; p < 0.01), at the total hip (+3.2%; p < 0.01) and at the trochanter (+4.5%; p < 0.01), whereas the CEE/MPA group showed a non-significant increase of bone mineral density at the lumbar spine (+2.6%) but no increases at the hip. Between-group differences in bone mineral density changes were significant (p < 0.05) for the total hip and the trochanter at 36 months. This increase of bone mineral density was not accompanied by changes in insulin-like growth factor-I (IGF-I) or insulin-like growth factor binding protein-3 (IGFBP-3) in either group. Osteocalcin, alkaline phosphatase and urinary ratios of hydroxyproline/creatinine and calcium/creatinine significantly decreased in both groups. In conclusion, sequential CEE/MPA prevented cortical and trabecular bone loss, with a transient increase of bone mineral density only during the first 6 months. Tibolone not only prevented cortical and trabecular bone loss, but further increased bone mineral density at the lumbar spine and at the hip throughout the 3 years of treatment, suggesting a sustained positive effect on bone mass.

Influence of anthropometric parameters and biochemical markers of bone metabolism on quantitative ultrasound of bone in the institutionalized elderly

The assessment of bone quality by quantitative ultrasound (QUS), a transportable and relatively cheap method, shows some correlations with bone mineral density (BMD) as measured by dual-energy X-ray absorptiometry (DXA) and with fracture risk. To examine its correlation with bone metabolism in a population of institutionalized elderly people known to be at high risk for vitamin D deficiency and secondary hyperparathyroidism, QUS of the calcaneus and biochemical parameters were measured in 264 women aged 85 +/- 7 (SD) years and in 103 men aged 81 +/- 8 years living in 19 nursing homes. Vitamin D deficiency was frequent in this population: 41.9% of the women and 31.4% of the men had a serum 25-hydroxyvitamin (25OHD) level below the 2.5th percentile level of 3276 normal Swiss adults (6.2 micrograms/l or 15.5 mmol/l). Hyperparathyroidism was less frequent: serum parathyroid hormone (PTH) levels were above the 97.5th percentile level of normal adults (70 pg/l) in 18.9% of women and 9.8% of men. In women, QUS data correlated significantly with age (r = -0.297), body mass index (BMI) (r = 0.403), calcium (r = 0.220), PTH (r = -0.296), 25OHD (r = 0.298) and alkaline phosphatase (AP) (r = -0.170) for broadband ultrasound attenuation (BUA), and with age (r = -0.195), BMI (r = 0.208), PTH (r = -0.174), 25OHD (r = 0.140) and AP (r = -0.130) for speed of sound (SOS). In men, ultrasound data correlated with BMI (r = 0.326), calcium (r = 0.199), 25OHD (r = 0.258) and AP (r = -0.311) for BUA, and with AP (r = -0.196) for SOS. In women, but not in men because of their smaller number, a multivariate analysis was performed to examine relationships between age, BMI, biochemical markers and QUS. Age, BMI, PTH and phosphate explained 30% of the variance of BUA and 10% for SOS. In conclusion, QUS of bone evaluates characteristics of bone that are influenced, at least partially, by age, BMI and the secondary hyperparathyroidism due to vitamin D deficiency.

Bone resorption in multiple myeloma and in monoclonal gammopathy of undetermined significance: quantification by urinary pyridinium cross-links of collagen

To quantify osseous breakdown in multiple myeloma (MM), monoclonal gammopathy of undetermined significance (MGUS), and benign osteoporosis, we measured urinary levels of pyridinium cross-links of collagen in 50 patients with newly diagnosed and untreated MM, 40 patients with MGUS, 40 untreated patients with osteoporotic vertebral fractures, and 64 healthy adults. Ion-paired, reverse-phase high-performance liquid chromatography (HPLC) was used to measure total urinary excretion of pyridinoline (h-PYD) and deoxypyridinoline (h-DPD). Urinary excretion of free immunoreactive deoxypyridinoline (i-DPD) was determined with an enzyme immunoassay. MM patients had significantly (P < .0001) higher levels of h-PYD, h-DPD, and i-DPD than the healthy adults, patients with MGUS, or patients with osteoporosis. The MGUS and osteoporosis groups presented with elevated (P < .05) levels of urinary pyridinium cross-links when compared with healthy controls. In 20 MM patients who subsequently received chemotherapy, the percent changes in i-DPD did not correlate with the changes in the monoclonal protein. In one of three patients experiencing a transition of initial MGUS into stage I MM, i-DPD increased above the upper limit of the normal range. In 13 patients with stable MGUS, i-DPD remained normal in repeated measurements. Based on the upper limits of the normal range, the sensitivity of urinary pyridinium cross-links in stage I and II MM was low (<50%), but it was between 78% (h-DPD) and 93% (i-DPD) in stage III MM. Specificity in patients with MGUS was between 87% (h-PYD) and 97% (h-DPD). In conclusion, determining the urinary excretion of pyridinium cross-links seems to be a promising noninvasive and thus easily repeatable method for evaluating the actual degree of osseous breakdown. Although measurement of pyridinium cross-link levels is not useful in discriminating patients with MGUS from early-stage myeloma patients, determination of i-DPD levels may contribute importantly to clinical guidance, since increased i-DPD levels seem to identify patients who are particularly likely to benefit from osteoclast-inhibiting drugs such as bisphosphonates. The fact that in a number of patients paraprotein concentrations and i-DPD levels did not change in parallel but instead diverged strongly after chemotherapy might explain the observation that bone lesions sometimes progress even in patients who achieve complete remission.

An in vitro and in vivo study of cytokines in the acute-phase response associated with bisphosphonates

We studied the acute phase response, including specific cytokine production, [interleukin-1 (IL-1), interleukin-6 (IL-6), tumor necrosis factor alpha(TNF alpha)] following a single dose of Aredia (disodium pamidronate) in patients with increased bone turnover and, in vitro, the role played by specific cytokines in the acute-phase reaction which may follow the administration of aminobisphosphonates. An in vivo exploratory study was done on 24 in- and outpatients with increased bone turnover given a single intravenous dose of pamidronate 60 mg. Measurements were taken at baseline and at 24, 48, and 72 hours. The main outcome measures were changes from baseline in serum IL-1, IL-6, and TNF alpha. In addition, C-reactive protein (CRP), white blood cell count (WCC), lymphocyte count, and elastase concentration were measured. Symptomatic evaluation was made of fever, bone pain, and rigors. In vitro, whole blood from eight healthy volunteers was exposed to various concentrations of the three bisphosphonates--pamidronate, clodronate, and zoledronate. Measurements were taken immediately before and at 3, 6, and 10 hours after exposure to drugs. The main outcome measures were changes in serum IL-1, IL-6, and TNF alpha. In vivo, there was a statistically significant (P < 0.001) increase in median values of TNF alpha in all post-baseline measurements. Median values for IL-6 also showed a significant (P < 0.001) increase at 24 hours after dosing. There were no statistically significant changes in median IL-1 values. Few patients showed any change from baseline in total WCC or in lymphocyte count, but 62.5% of patients with normal range baseline values for CRP increased to above normal levels after treatment. Fourteen patients experienced fever; 2 reported rigors. There was no correlation between fever and changes in cytokines. There were no serious adverse experiences or premature discontinuations due to poor tolerability, and 91% of the patients expressed willingness to receive pamidronate again. In vitro, an increase in TNF alpha and a mild increase in IL-6 was seen with all bisphosphonates, with the greatest effects seen with the highest concentration of both pamidronate and zoledronate. No changes were observed in IL-1 with any agent. Significant changes in both TNF alpha and IL-6 were observed within 3 days of a single dose of pamidronate in patients treated for the first time confirming previous findings. However, the lack of change in IL-1 in vivo and in vitro does not support the hypothesis that this cytokine plays a major role in the acute phase reaction. The cellular mechanism of the interaction among aminobisphosphonates, IL-6, and TNF alpha requires further investigations. The results of the in vitro study are consistent with the in vivo findings.

Three monthly intravenous injections of ibandronate in the treatment of postmenopausal osteoporosis

PURPOSE

Oral treatment of osteoporosis with bisphosphonates relies on compliance, the absorption being low and suppressed by simultaneous food intake. Intravenous (IV) treatment with an aminobisphosphonate, pamidronate (once every 3 months) was effective, but required infusions. Ibandronate, a new very potent aminobisphosphonate, can be administered safely as an IV bolus injection, and therefore offers an interesting alternative suitable for outpatient treatment.

PATIENTS AND METHODS

To test the efficacy of this bolus IV treatment in postmenopausal osteoporosis in randomized partly double-blind, placebo controlled study, 125 postmenopausal women (mean age, 64 years) with osteoporosis (bone mineral density [BMD] < -2.5 SD T score) received a placebo or ibandronate (0.25, 0.5, 1, or 2 mg) every 3 months. All patients received 1 g calcium/day. BMD, in g/cm2, was measured by dual-energy x-ray absorptiometry at all standard sites.

RESULTS

Lumbar spine BMD (L2 to L4) did not change (0.85%) in the placebo group, but increased by 2.4%, 3.5%, 3.7%, and 5.2% at 12 months for dose-ranging groups (no significant differences among ibandronate groups). The increase was statistically significantly different from placebo for the 0.5 mg (P < 0.006), 1 mg (P < 0.004), and 2 mg (P < 0.001) group, whereas with 0.25 mg no significant differences occured. After 1 year there were no significant changes in BMD compared with placebo at the femoral neck, Ward's triangle, and distal forearm. Total hip and trochanter BMD increased significantly, by 1.8% and 2.9% for total hip and by 2.7% and 4.2% for trochanter in the 1 and 2 mg group, respectively. Urinary excretion of C-telopeptide and N-telopeptide decreased after 1 month in all ibandronate groups, with a clear dose dependency. Three months after the first injection of 2 mg ibandronate there was still a significant reduction in these markers of bone resorption. Osteocalcin decreased progressively and dose dependently over time. There was a correlation between the decrease in C-telopeptide measured after 1 month and the increase in lumbar spine BMD after 1 year (n = 115, r = -0.26, P < 0.012). Ibandronate therapy proved to be safe. There was no significant difference in the overall number of adverse events in the ibandronate groups compared with the placebo group. Considering specific adverse events, no dose dependency and difference to placebo could be observed apart from acute reactions that occurred in 7% of the patients.

CONCLUSION

Treatment of postmenopausal osteoporosis by interval IV bolus injections of the bisphosphonate ibandronate was safe and effective in increasing BMD through a dose-dependent inhibition of bone resorption. The high potency of ibandronate allows 3-month interval bolus IV injections as a new therapeutic approach with optimal compliance.

Dose-response study of ibandronate in the treatment of cancer-associated hypercalcaemia

Hypercalcaemia is an important cause of morbidity in malignant disease. We studied the efficacy and safety of intravenous ibandronate (a new, potent bisphosphonate) in a multicentre study of 147 patients with severe cancer-associated hypercalcaemia which had been resistant to treatment with rehydration alone. Of 131 randomized patients who were eligible for evaluation, 45 were allocated to receive 2 mg ibandronate, 44 patients to receive 4 mg and 42 patients to receive 6 mg. Serum calcium values fell progressively in each group from day 2, reaching a nadir at day 5, and in some patients normocalcaemia was maintained for up to 36 days after treatment. The 2-mg dose was significantly less effective than the 4-mg or 6-mg dose in correcting hypercalcaemia, as the number of patients who achieved serum calcium values below 2.7 mM after treatment was 50% in the 2-mg group compared with 75.6% in the 4-mg group and 77.4% in the 6-mg group (P < 0.05; 2 mg vs others). In a logistic regression analysis, three factors were found to predict response; ibandronate dose (higher doses were more effective), severity of presenting hypercalcaemia (severe hypercalcaemia was associated with less complete response) and tumour type (patients with breast carcinoma and haematological tumours responded better than those with other tumours). Ibandronate was generally well tolerated and no serious drug-related adverse events were observed. We conclude that ibandronate is a safe, well tolerated and effective treatment for cancer-associated hypercalcaemia, which should prove a useful addition to the current range of therapies available to treat this condition.

Importance of albumin, 25(OH)-vitamin D and IGFBP-3 as risk factors in elderly women and men with hip fracture

The relative importance of vitamin D deficiency, secondary hyperparathyroidism, nutritional deficiency and low bone mineral density (BMD) as risk factors for hip fracture is not definitely established. In the framework of a case-control study of risk factors for hip fractures, biochemical markers of bone metabolism and nutrition and femoral BMD data were compared in 136 female and 43 male hip fracture patients, 136 female and 44 male age-matched hospitalized controls, and 47 healthy elderly women (8 men). Patients with hip fracture had lower albumin (-10%) and 25(OH)-vitamin D (25(OH)D; -19%) compared with hospitalized controls, and lower albumin (-28%) and 25(OH)D levels (-52%) compared with the elderly controls. Serum values of IGFBP-3 were also significantly lower (-33%) in hip fracture patients than in community controls. BMD of femoral neck was lower (p < 0.001) in patients than in hospitalized and community controls. In hip fracture patients, parathyroid hormone (PTH) correlated weakly with BMD (neck: r = -0.19, trochanter: r = -0.17; both p < 0.05). When all women were pooled (n = 233), albumin correlated significantly (age-adjusted) with BMD at all sites (neck: r = 0.27, trochanter: r = 0.25; all p < 0.001). Albumin, but not 25(OH)D, also correlated with skinfold thickness (r = 0.19, p < 0.0025) and with body mass index (BMI) (r = 0.14, p < 0.05). Male patients with hip fracture had lower BMD and albumin (both p < 0.001), 25(OH)D (p = 0.02) and IGFBP-3 levels (p < 0.005) compared with the controls. When male patients and controls were pooled together, albumin, skinfold thickness and BMI were significantly correlated with each other, but not with BMD. IGFBP-3 was highly correlated with albumin (p < 0.0001), 25(OH)D (p < 0.005) and, less significantly, with PTH (p < 0.05), but not with BMI or skinfold thickness. IGFBP-3 was significantly correlated with BMD at all sites (neck: r = 0.27, p < 0.05; trochanter: r = 0.40, p < 0.0005). In conclusion, low albumin and low BMD were both important risk factors for hip fracture. Low serum albumin was the strongest independent variable correlated with hip fractures. In men. IGFBP-3 was correlated with BMD. The femoral BMD depended only weakly on PTH and 25(OH)D, but was correlated at all sites with albumin, a non-specific parameter of nutrition and general health.

Segmental body composition assessed by bioelectrical impedance analysis and DEXA in humans

The present study assessed the relative contribution of each body segment to whole body fat-free mass (FFM) and impedance and explored the use of segmental bioelectrical impedance analysis to estimate segmental tissue composition. Multiple frequencies of whole body and segmental impedances were measured in 51 normal and overweight women. Segmental tissue composition was independently assessed by dual-energy X-ray absorptiometry. The sum of the segmental impedance values corresponded to the whole body value (100.5 +/- 1.9% at 50 kHz). The arms and legs contributed to 47.6 and 43.0%, respectively, of whole body impedance at 50 kHz, whereas they represented only 10.6 and 34.8% of total FFM, as determined by dual-energy X-ray absorptiometry. The trunk averaged 10.0% of total impedance but represented 48.2% of FFM. For each segment, there was an excellent correlation between the specific impedance index (length2/impedance) and FFM (r = 0.55, 0.62, and 0.64 for arm, trunk, and leg, respectively). The specific resistivity was in a similar range for the limbs (159 +/- 23 cm for the arm and 193 +/- 39 cm for the leg at 50 kHz) but was higher for the trunk (457 +/- 71 cm). This study shows the potential interest of segmental body composition by bioelectrical impedance analysis and provides specific segmental body composition equations for use in normal and overweight women.

Influences of body weight, body composition, and substrate oxidation rate on resting postabsorptive glucose production and gluconeogenesis

OBJECTIVE

To determine the influence of body weight, fat mass, and fat distribution on resting endogenous glucose production in healthy lean and overweight individuals.

DESIGN

measurements were performed in the resting postabsorptive state in individuals receiving an unrestricted diet.

SETTING

Institute of Physiology of Lausanne University.

MEASUREMENTS

resting post absorptive glucose production, glycogenolysis and gluconeogenesis; resting energy expenditure and net substrate oxidation.

RESULTS

Endogenous glucose production was positively correlated with body weight, lean body mass, energy expenditure and carbohydrate oxidation. Gluconeogenesis was positively correlated with net lipid oxidation and energy expenditure, and negatively correlated with net carbohydrate oxidation. No correlation with body fat or fat distribution was observed.

CONCLUSIONS

Gluconeogenesis shows a large interindividual variability. Net lipid oxidation and not body fat appears to be a major determinant of gluconeogenesis.

[Importance of the clinical profile in the postmenopausal osteoporosis screening by densitometry]

In order to test the impact of a given risk profile on the incidence of osteoporosis which could justify BMD measurement, and that of a low risk profile which could render it unnecessary, BMD was measured in 217 women under 72 in whom menopause had occurred at least 6 years previously and who corresponded to one of the two following profiles: high risk (A, n = 102) = BMI < 27 kg/m2, with no estrogen replacement treatment, and with at least one of the following risk factors: BMI < 20, early menopause, positive family history, no dairy products associated with tobacco consumption (> 10 cigarettes/day for > 20 years and/or alcohol consumption of > 0.5 l wine/day during > 10 years, corticotherapy of > 6 months, rickets, anorexia nervosa. Low risk (B, n = 115) = absence of characteristics of group A, BMI > 27 kg/m2 with (B+, n = 24) or without estrogen therapy (B-, n = 91). BMD was measured by DXA in 4 centers using Lunar or Hologic equipment. Results were expressed in % of the mean of the respective young adult control groups. As expected, BMD was significantly different in these two subgroups of the population. Osteoporosis was diagnosed (BMD < 75% = < -2.5 SD, according to WHO) in 72% of group A, and in 17% (B+) and 19% (B-) respectively of group B. There was no difference between the various risk factors in group A concerning their impact on BMD, but concerning incidence, low BMI and early menopause were the most frequent. The high risk profile of group A seems to justify densitometry, since it leads to the diagnosis of osteoporosis in over 70%. However, the protective profile of group B does not exclude osteoporosis (risk still 20%); only in severe obesity (BMI > 33) does it drop to 1%.

Cyclosporine induces high bone turnover and may contribute to bone loss after heart transplantation

Cardiac transplantation has become a successful therapy for end-stage heart disease. However, increased bone loss has been observed in heart transplant recipients, sometimes being responsible for osteoporotic fractures. Glucocorticoids cause dose-related bone loss, particularly in the first 6-12 months of use, but cyclosporine might play a role as well. The evolution of bone mineral density (BMD) and biochemical parameters was prospectively assessed in 24 patients (mean age 52 years) from cardiac transplantation. All patients received cyclosporin A (CsA) and prednisone, the latter at decreasing dosage. The mean current daily dose of CsA was 321 mg and serum levels of CsA were constant. All patients received calcium (500 mg day-1) and vitamin D (1000 U day-1) for prevention of bone loss. BMD (gcm-2) was measured in 17 patients at the lumbar spine, femoral neck and total hip with dual energy X-ray absorptiometry every 6 months. Spinal BMD as well as neck and total hip BMD decreased at 6 and 12 months after transplantation, being statistically significant at the three sites: -5.6 and -3.4% for the lumbar spine, -9.3 and -8.5% for the femoral neck, -4.8% and -6.0% for the total hip respectively. Parathyroid hormone (PTH) and osteocalcin (BGP) increased by 90% and 800% respectively between pretransplantation values and 18 months after transplantation. BGP levels measured every 2 months from transplantation increased continuously from 8.7 micrograms L-1 (mean +/- SEM) before transplantation to 31.3 +/- 10.1 (P < 0.05) at 4 months, to 59.1 +/- 8.8 (P < 0.01) at 6 months and to 72.2 +/- 9.9 (P < 0.01) at 18 months (Kruskal-Wallis analysis: P < 0.0001). PTH showed a biphasic pattern with an initial decrease from 39.3 +/- 4.1 ng L-1 at baseline to 22.0 +/- 2.8 ng L-1 at 2 months, but increasing thereafter to 45.9 +/- 5.7 at 6 months and 74.2 +/- 8.9 at 18 months (Kruskal-Wallis analysis: P < 0.001). These variations represent a glucocorticoid-induced osteoporosis. In summary, cardiac transplant patients lose bone immediately after transplantation at the spine and the hip. Later on, the loss in BMD discontinues at all sites of the skeleton, but predominantly at the spine, and a few patients still lose bone at the hip. This is probably a result of the high bone turnover either due to secondary hyperparathyroidism or induced by cyclosporin A.

Bone densitometry of the forearm: comparison of single-photon and dual-energy X-ray absorptiometry

Forearm bone mineral densitometry was performed initially by single-photon absorptiometry (SPA), but is now achievable by dual-energy X-ray absorptiometry (DXA) as well, with a good correlation between both measurements. However, it is still unknown whether: (1) short-term precision of DXA is superior to SPA and (2) identical regions of interest (ROI) are mandatory to correlate SPA with DXA. The aim of this study was to answer these questions using a commercial system for DXA (DXA-FAS) and to test an in-house system using spine DXA and a soft-tissue compensator (DXA-STC). In ten subjects, four measurements on the same day showed significantly lower (p < 0.05) coefficients of variation (CV) for bone mineral density (BMD) by DXA-FAS (proximal site: 0.74%; ultradistal site: 1.20%) than by SPA (1.26% and 2.25%). However, the CV for bone mineral content (BMC) were similar for DXA-FAS (0.73% and 1.58%) and SPA (0.79% and 1.34%). The significant difference (p < 0.05) for surface calculation by DXA-FAS (1.24% and 0.93%) compared with SPA (2.36% and 1.28%) explains all the advantages of DXA-FAS for short-term precision. The measurements taken on the same day on the ulna and the radius or on the radius alone by SPA, DXA-FAS, and DXA-STC on 108 subjects aged 18-80 years were highly correlated [r ranging from 0.925 to 0.995 (p < 0.0001) and standard error of the estimate from 3.15% to 8.89%]. The need for a manual adjustment of the ROI was found to be mandatory for BMC but not BMD assessment. The use of DXA-STC is a fast method for forearm bone densitometry and its correlation with SPA is very high. However, its short-term precision for BMC (3.00% and 1.54%), BMD (2.15% and 1.12%), and surfaces (1.99% and 1.12%) is significantly higher (p < 0.05) than that of DXA-FAS. We conclude that short-term precision of DXA is better than that of SPA only for BMD and surface measurement but not for BMC. ROI should be adjusted manually for the assessment of BMC but not for that of BMD.

Bone mineral content in cystic fibrosis patients: correlation with fat-free mass

OBJECTIVE

To assess the bone mineral content in well nourished patients with cystic fibrosis and to seek a correlation with fat-free mass.

METHODS

Fourteen cystic fibrosis patients aged 6 to 20 years were studied and compared to 14 healthy controls matched for gender, age, and nutritional status. Bone mineral content was determined by dual energy x ray absorptiometry (DEXA).

RESULTS

Nutritional inquiry showed higher ingestion of macronutrients and micronutrients by cystic fibrosis patients than by controls. Mean whole skeleton bone mineral content was 1.184 (SD 0.536) kg in cystic fibrosis patients and 1.229 (0.576) kg in controls (p = 0.84). Mean lumbar spine bone mineral content was 0.031 (0.013) kg and 0.031 (0.016) kg, respectively (p = 0.99). Anthropometry, bioelectrical impedance analysis, and DEXA showed that fat-free mass was similar in the two groups. Bone mineral content was strongly correlated to fat-free mass. Mean blood calcium, phosphorus, serum 25-hydroxyvitamin D (25-OHD), parathyroid hormone (PTH), and osteocalcin were similar in both groups.

CONCLUSIONS

Bone mineral content and body composition are normal in a well nourished young cystic fibrosis population. Osteopenia previously reported in cystic fibrosis patients probably has nutritional origins and is therefore not related to a primary defect in bone mineral metabolism.

[Evaluation of bones using quantitative ultrasonography]

The evaluation of bone by ultrasound is a new, transportable and non-irradiating method. It measures attenuation of ultrasound (BUA), as well as velocity (SOS) of ultrasound in a given tissue. For the measurement of bone, the most frequently used bone is the calcaneus. We have used this technique (Achilles, Lunar) to evaluate the reproducibility of measurements in healthy volunteers and to determine the correlations between the results of ultrasound measurements and those of conventional densitometry (DXA) in a population of postmenopausal females who consulted for screening or diagnosis of osteoporosis. Although several publications have already dealt with the same questions, it is important to reexamine them locally before the technique is uncritically used even in unspecialized centers. The coefficients of variation corresponded to that reported by others: 1.8% for BUA and 0.3% for SOS. The correlations between the ultrasound measurements and the results of DXA at lumbar spine, femoral neck and calcaneus in 57 postmenopausal women aged +/- 59 (43-78) years and in part osteoporotic (DXA results below 2.5 SD-T-score) (Hologic QDR 2000) were all significant (p < 0.001). The best correlation between the two techniques (DEXA and ultrasound) is found when applied to the same site, i.e. the calcaneus (r > 0.8). These results also agree with the literature. Low ultrasound values (BUA < 100 dB/MHz, SOS < 1495 m/s) are highly suggestive of osteoporosis, while high ultrasound values are almost exclusively found in non-osteoporotic women. This information provides the basis for further investigations, such as correlation with fracture risk, in cross-sectional and longitudinal studies.

Randomized phase II trial comparing different doses of the bisphosphonate ibandronate in the treatment of hypercalcemia of malignancy

PURPOSE

To evaluate the hypocalcemic effect and safety of three different doses of the bisphosphonate ibandronate in tumor-associated hypercalcemia, and to identify factors predicting response.

PATIENTS AND METHODS

One hundred seventy-four cancer patients with a serum calcium level greater than 2.7 mmol/L (10.8 mg/dL) were enrolled onto the trial. If hypercalcemia persisted after fluid repletion, patients were randomly assigned to treatment with 0.6 mg, 1.1 mg, and 2.0 mg of ibandronate. Response, defined as restoration of normocalcemia, was evaluated by an intent-to-treat analysis.

RESULTS

One hundred seventy-three (99%) patients were assessable for toxicity and 151 (87%) for efficacy. The administration of 0.6 mg (group A), 1.1 mg (group B), or 2.0 mg (group C) of ibandronate led to response rates of 44%, 52%, and 67%, respectively. Significantly more patients in group C responded than in group A (P = .0276). Of the various parameters examined, only the initial serum calcium level (P < .0001; odds ratio, 0.083) and the dose of ibandronate (P = .0162; odds ratio, 2.094) correlated with response. One hundred ninety-five adverse events (AEs) were reported, 99 classified as serious and 96 as nonserious. Three serious and sixteen nonserious AEs were considered related to ibandronate treatment. The three serious AEs were one case with thrombocytopenia, one with nausea, and one with fever.

CONCLUSION

Ibandronate therapy led to a dose-dependent reduction in serum calcium levels. The response to ibandronate treatment correlated negatively with the initial serum calcium level and positively with the dose administered. A dose of 2 mg was necessary to achieve a response rate comparable to that in previous studies with the bisphosphonates pamidronate and clodronate. Because the incidence of drug-associated AEs was low, a dose escalation of ibandronate can be recommended for further clinical trials.

Quantitative ultrasound of bone in institutionalized elderly women: a cross-sectional and longitudinal study

Quantitative ultrasound of bone is a promising method for bone assessment: radiation-free, portable and predictive of hip fracture. Its portability allowed us to study the relationships between ultrasonic parameters of bone with age and with non-vertebral fractures in elderly women living in 19 nursing homes. Broadband ultrasound attenuation (BUA) and speed of sound (SOS) of the calcaneus were measured (and the stiffness index calculated) in a sample of 270 institutionalized women, aged 85 +/- 7 years, using an Achilles bone densitometer (Lunar). The effects of age, history of non-vertebral and non-traumatic fractures, body mass index, triceps skinfold and arm circumference were assessed on BUA, SOS and stiffness index. Furthermore, to evaluate longitudinally the influence of aging on the ultrasound parameters of bone, 60 subjects from the same group had a second ultrasound measurement after 1 year. The cross-sectional analysis of the data on all 270 women showed a significant decrease (p < 0.001) with age in BUA, SOS and stiffness index (-0.47%, -0.06%, and -1.01% respectively per year). In the 94 women, (35%) with a history of previous non-vertebral fractures, ultrasound parameters were significantly lower (p < 0.0001) than in the 176 women with no history of fracture (-8.3% for BUA, -1.3% for SOS, -18.9% for stiffness index). In contrast, there was no significant difference in anthropometric measurements between the groups with and without previous non-vertebral fractures, although the measurements decreased significantly with age. In the longitudinal study, repeated quantitative ultrasound after 11.4 +/- 0.8 months showed no significant decrease in BUA (-1%) but a significant decrease in SOS (-0.3%, p < 0.0001) and in stiffness index (-3.6%, p < 0.0002). In conclusion, quantitative ultrasound of the calcaneus measures properties of bone which continue to decline in institutionalized elderly women, and is able to discriminate women with previous non-vertebral fractures.

[Prevention of osteoporosis and role of densitometry]

Osteoporosis is a major public health problem in countries with aging populations, resulting in excess morbidity and mortality. Osteoporosis is defined as a systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue, with the consequent increase in bone fragility and susceptibility to fractures. Therefore, the bone loss that precedes fractures is a continuous process that is often mostly irreversible in the aging. The most efficient method of preventing fractures is the prevention of bone loss. The measurement of bone mass and other skeletal characteristics can effectively identify women at high risk for fractures. The measurement of bone mass which can be carried out by osteo-densitometry is now widely available. It is the only clinical data that can provide accurate assessment of individual fracture risk. Treatments exist that will preserve bone mass and presumably reduce fracture risk; therefore there is a place for screening of patients at high risk of fractures. Many studies have shown recently that a reduced bone mass (at least 1 standard deviation below normal) was associated with a more than 100% increased risk of fracture. Thus the initial assessment of bone mass can be used to estimate future fracture risk and to start prevention measures for high risk patients. Primary prevention can be initiated during the adolescence to optimize peak bone mass. Later in life, secondary prevention can prevent excessive bone loss and more specific treatments can prevent postmenopausal and age related bone demineralization. Strategies of prevention should be promoted and validated as general health care strategies.

The diagnostic value of urinary pyridinium cross-links of collagen, serum total alkaline phosphatase, and urinary calcium excretion in neoplastic bone disease

Bone metastases strongly affect skeletal metabolism by both their growth and their paracrine activities. However, so far no specific laboratory marker has been found to signal the spread of neoplastic disease to bone. We performed a cross-sectional study of 153 cancer patients and an equal number of healthy controls matched for sex and age, in which we determined serum levels of calcium and total alkaline phosphatase (TAP) as well as the fasting urinary excretion of calcium (uCa) and of the collagen cross-links pyridinoline (uPYD) and deoxypyridinoline (uDPD). The aim of the study was to analyze the diagnostic validity of the biochemical parameters measured with regard to neoplastic bone involvement. In the cancer group, 98 patients had overt bone metastases, as judged from radiographic and radioisotopic bone imaging. The remaining 55 patients were also in an advanced stage of disease, but there was no evidence of malignant bone involvement. In comparison to healthy controls, patients both with and without metastatic bone disease had significantly higher levels of TAP, uPYD, and uDPD (P < 0.0001). Only in cancer patients with bone metastases was the median serum calcium level higher than in the healthy controls (P < 0.02). uCa was the same in cancer patients and the control group. Within the collective of cancer patients, individuals with skeletal metastases had higher levels of serum calcium (P < 0.05), TAP (P < 0.01), and uPYD and uDPD (both P < 0.0001), than patients without evidence of malignant bone disease. uCa did not differ between the 2 groups of cancer patients. The cancer patients were then stratified into 4 subgroups according to the serum calcium level (< or = 2.6 mmol/L >) and the absence or evidence of bone metastases. This stratification revealed that in patients with bone metastases, uPYD and uDPD levels were similar in normocalcemic and hypercalcemic subjects, whereas in hypercalcemic patients, uCa levels significantly exceeded those in normocalcemic patients. When the efficacy of TAP, uCa, uPYD, and uDPD in discriminating between patients with and without bone metastases was evaluated by use of receiver-operating characteristic curves and stepwise multivariate regression analysis, uPYD was found to have the highest diagnostic validity. Using 50 mumol PYD/mol creatinine (i.e. the upper limit of normal range) as the cut-off level, the sensitivity of uPYD was 88.7%, whereas the specificity was only 41.8% (odds ratio, 5.598; 95% confidence interval, 2.547-12.306).(ABSTRACT TRUNCATED AT 400 WORDS)

Regulation of collagen type I and biglycan mRNA levels by hormones and growth factors in normal and immortalized osteoblastic cell lines

Growth factors, such as transforming growth factor beta (TGF-beta) and insulin-like growth factors (IGF) I and II, have been shown to exert anabolic effects on bone cells in vitro. Hormones, such as PTH and probably insulin and growth hormone, were recently shown to stimulate bone formation in vivo as well. The aim of the present study was to assess by northern blots, which were quantitated by densitometry, the effects of these anabolic growth factors and hormones in two osteogenic cell populations: CRP 10/30 cells, a clonal cell population derived from primary rat calvarial cells, and IRC 10/30-myc cells, which were established from CRP 10/30 by immortalization. Transcripts for alpha 1(I) collagen, biglycan, osteonectin, osteopontin, and osteocalcin were detected in both cell populations, which is consistent with the phenotype expressed by mature osteoblasts. There were no difference in the basal expression of bone matrix mRNAs between the two cell populations. PTH increased alpha 1(I) collagen mRNA levels in both osteoblastic cells but had no effect on the biglycan transcripts. Neither insulin nor growth hormone affected mRNA levels of either matrix protein after 24 h exposure. All three growth factors, TGF-beta, IGF-I, and IGF-II, increased alpha 1(I) collagen transcripts in a time- and dose-dependent manner in both cell populations. Biglycan mRNA levels were enhanced in both osteoblastic lines only by IGF-I and IGF-II, but not TGF-beta.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of treatment of malignancy-associated hypercalcemia on serum parathyroid hormone-related protein

Parathyroid hormone-related protein (PTHrP) is the primary mediator of hypercalcemia in patients with malignancy-associated hypercalcemia. We conducted this study to examine the effects of treatment with a bisphosphonate on serum PTHrP. We analyzed 41 episodes of hypercalcemia occurring in 38 patients: 22 patients received alendronate, and 16 were treated with pamidronate. At baseline, 29 patients had an increased serum PTHrP (group I) and 9 had low or undetectable levels (group II). The two groups did not differ significantly in baseline hypercalcemia (3.26 versus 3.41 mM) or the response of serum calcium to therapy. Serum calcium was normalized in 88% of group I and 70% of group II patients. Lowering of the mean calcium level was not associated with a change in the level of PTHrP in group I patients (40.2 versus 36.7 pgEq/ml) or group II patients. We also analyzed data on serum PTH and 1,25-(OH)2D in 20 of the patients. Serum PTH rose with treatment in group I patients (9.7-40.2 pg/ml, p < 0.05), as did the serum 1,25-(OH)2D (19.1-32.4 pg/ml, p < 0.001). Similarly, treatment of group II patients was associated with an increase in serum PTH (9.8-37.2 pg/ml) and serum 1,25-(OH)2D (22.9-40.2 pg/ml). The individual increases in 1,25-(OH)2D levels associated with therapy could not be predicted from the level of PTHrP or the changes in levels of serum calcium or PTH. Our data show that effective treatment of malignancy-associated hypercalcemia is not associated with a consistent change in serum levels of PTHrP. Therapy is associated with a variable increase in the serum levels of PTH and 1,25-(OH)2D.

Two years' effectiveness of intravenous pamidronate (APD) versus oral fluoride for osteoporosis occurring in the postmenopause

Bisphosphonates seem to be effective as antiresorptive agents in the prevention and treatment of osteoporosis. However, the optimal dose and route of administration as well as the specific effects on cortical or trabecular bone have not been clarified. To compare pamidronate (APD) with fluoride (F) in the therapy of postmenopausal osteoporosis, 32 osteoporotic women were treated for 2 years either with APD (30 mg as a single intravenous infusion over 1 h every 3 months, n = 16, mean age 65 years) or with fluoride orally (20-30 mg F/day, n = 16, mean age 67 years) in an open study. Both groups received 1 g calcium and 1000 U vitamin D per day, but no estrogens or other drugs acting on bone. Both groups showed the same initial mean number of fractures per patient (2.8 and 2.7). Bone densitometry was performed every 6 months at three sites: lumbar spine and hip with dual-energy X-ray absorptiometry (BMD), distal forearm with single photon absorptiometry and lumbar spine with quantitative computed tomography. Biochemical assessment was performed in blood and urine every 3 months. Lumbar BMD (g/cm2, mean +/- SEM) increased from 0.632 (+/- 0.030) at time 0 to 0.696 (+/- 0.028) at 24 months in the APD group (p < 0.001), and from 0.684 (+/- 0.025) to 0.769 (+/- 0.028) in the fluoride group (p < 0.001). Femoral neck BMD increased significantly from 0.558 (+/- 0.025) to 0.585 (+/- 0.025) (p < 0.01) in the APD group, whereas it did not change in the fluoride group.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct evidence of a parathyroid related protein gradient between the mother and the newborn in humans

Umbilical cord plasma has increased parathormone (PTH)-like bioactivity in comparison with that in maternal plasma, but suppressed PTH levels. Previous attempts to detect elevated levels of PTHrP(1-34) in the umbilical cord were unsuccessful, whereas PTHrP was detected by immunohistochemistry in both fetal parathyroid glands and placental membranes. At the time of delivery, plasma samples were drawn simultaneously from 47 normal mothers (mean age, 26 years) and from the umbilical cord of 25 female and 22 male newborns and assessed for calcium adjusted for albumin, magnesium, creatinine, intact PTH and PTHrP. PTHrP was measured using a new 2-site immunoradiometric assay recognizing separately 1-40 and 60-72 residues with a sensitivity of 0.3 pmol/l. Mean (+/- S.D.) plasma calcium values were 2.35 +/- 0.10 in the mothers versus 2.63 +/- 0.12 mmol/l in the newborns (P < 0.001). PTH values were significantly higher in the mothers, as expected (22.3 +/- 14.8 vs. 6.2 +/- 0.9 pg/ml). In contrast, PTHrP values were significantly higher in the newborns (1.50 +/- 0.39 versus 0.84 +/- 0.28 pmol/l, P < 0.001). Only 1/47 mother had a PTHrP level higher than her child (0.9 vs. 0.8 pmol/l). Only 10/47 mothers had PTHrP higher than 1 pmol/l whereas only 1/47 newborn had a value below 1 pmol/l. There was no correlation between Ca and PTHrP in either group. Serum creatinine values were all within the normal range. Serum magnesium levels were not different between the mothers and the children.(ABSTRACT TRUNCATED AT 250 WORDS)

Methylpentylaminopropylidenebisphosphonate (BM 21.0955): a new potent and safe bisphosphonate for the treatment of cancer-associated hypercalcemia

Bisphosphonates have been shown to be effective in lowering serum calcium levels in patients with cancer-associated hypercalcemia. 1-Hydroxy-3-(methylpentylamino)propylidenebisphosphonate (BM 21.0955) was developed as a third generation bisphosphonate and has been recently proven effective in animals and in patients with Paget's disease or tumor osteolysis. Thirty-six patients with cancer-associated hypercalcemia were treated with increasing doses (0.2-2.0 mg) of BM 21.0955 by single i.v. infusion over 4 h in a phase I trial. Six patients were rejected from analysis due to concomitant treatment with other bisphosphonates or chemotherapy. After rehydration and infusion of BM 21.0955 the mean serum calcium levels fell significantly (P < 0.001), from 3.29 +/- 0.49 mmol/l to 3.04 +/- 0.44 mmol/l until day 2 and normalized on day 6 (2.66 +/- 0.33 mmol/l). Serum calcium was reduced in all patients and normalized in 16. No symptomatic hypocalcemia occurred. Mean serum creatinine decreased significantly (P < 0.01), from 1.25 +/- 0.58 mg/dl (day 0) to 1.05 +/- 0.37 mg/dl (day 6). The mean urinary calcium/creatinine concentration fell significantly (P < 0.001), from 1.90 +/- 1.16 mM/mM (day 0) to 0.37 +/- 0.34 mM/mM/l (day 6). There were no subjective drug-related side effects during or after the infusion. Thirteen patients had elevations of morning body temperature above 38 degrees C. This was due to confirmed infections in five patients and possibly drug- or tumor-related in the other eight. We conclude from these preliminary results that a single infusion of BM 21.0955 is an effective and safe way to treat cancer-associated hypercalcemia.

[Moderate Paget's disease treated with pamidronate (APD): experience in 43 patients with a single 60 mg infusion of varying duration of 1-to-24 hours]

Pamidronate disodium (APD) given as a single 60 mg intravenous infusion over 24 hours was shown to be an effective treatment for Paget's disease of bone. To further improve the feasibility of a simple treatment that ensures compliance in elderly outpatients (pts), we investigated the effectiveness of a single 60 mg APD intravenous infusion given over 8 hours (12 pts), 4 hours (9 pts) and 1 hour (10 pts) compared with that over 24 hours (12 pts). Infusion rate of APD was 7.5, 15 and 60 mg/h respectively, in comparison with 2.5 mg/h previously. Clinical improvement and biochemical remission were observed in all patients. Side effects, limited to mild transient fever and local transient increase in bone pain, occurred in 9 patients (2-3 pts in each group). There was no difference in the fall of plasma alkaline phosphatase and of urinary hydroxyproline between the 4 infusion rates. Plasma alkaline phosphatase (U/l, mean +/- SEM) decreased from 263 +/- 34 to 110 +/- 8 (1 h infusion), from 251 +/- 26 to 102 +/- 9 (4 h), from 237 +/- 23 to 95 +/- 9 (8 h) and from 256 +/- 29 to 97 +/- 7 (24 h), from day 0 to day 180 respectively (all p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Plicamycin and pamidronate in symptomatic tumor-related hypercalcemia: a prospective randomized crossover trial

We have conducted a randomized crossover comparative trial of a single-dose course of disodium (3-amino-1-hydroxypropylidene) bisphosphonate pentahydrate (pamidronate) and plicamycin in 48 patients with a first occurrence of tumor-related hypercalcemia. All patients had hypercalcaemia-associated symptoms and serum-calcium levels (corrected for total protein) greater than or equal to 2.80 mmol/l. Pamidronate and plicamycin were given concurrently with rehydration immediately after diagnosis of hypercalcaemia was made. Both agents lowered serum calcium levels significantly within 1 week, with 88% of the evaluable patients in the pamidronate group and 45% of those in the plicamycin group achieving normocalcemia (p less than 0.01). In the patients who received pamidronate, the duration of normocalcemia was longer (p less than 0.05) and there was a significant decrease in serum creatinine (p less than 0.05). Vomiting occurred in 8 of 22 evaluable patients (36%) who received plicamycin, but in none of 25 evaluable patients who received pamidronate (P less than 0.01). Phlebitis occurred at the infusion site in more of the pamidronate-treated patients (P less than 0.05). Hypocalcemia, which occurred in 8 of 25 evaluable patients (32%) in the pamidronate group and in 1 of 22 of those (5%) in the plicamycin group, was either clinically asymptomatic or mild, except in one pamidronate-treated patient. Overall, pamidronate was found to be more effective and better tolerated than plicamycin, thereby confirming results of previous studies that showed pamidronate to be an effective, simple, and safe agent for the relief of the morbidity associated with tumor-related hypercalcemia.

[Prevalence of risk factors for osteoporosis and distribution of calciuria and hydroxyprolinuria in an elderly population of a general practice. Results of a survey among 32 practitioners of the Vaud and Fribourg districts]

169 postmenopausal women and 84 male patients aged over 59 years from the outpatient consultations of 32 general practitioners were examined. The most frequently encountered risk factors for osteoporosis were low physical activity (41% of women, 27% of men), low intake of dairy products (37%/21%), smoking (11%/22%), while the particularly relevant risk factors were more rare, such as corticotherapy (7%/9%) and early menopause (17%). The risk factors were not more frequent than in 550 persons of the same age screened among the Swiss general population in another study. The same group of persons also yielded reference values for urinary calcium and hydroxyproline in the fasting urine, which are both considered as markers of bone turnover and as potential tools for screening osteoporosis. The urinary values were independent of age, body mass index, calcium intake, and the duration of the postmenopausal period. They were different from those found in 38 patients with Paget's disease, 66 patients with malignant hypercalcemia and 25 with bone metastasis from breast cancer. Calcium and hydroxyproline excretion are expressed as a ratio of urinary creatinine. Percentiles 10 and 90 of urinary calcium are 0.058 and 0.363 mmol/mmol (male) and 0.062 and 0.523 mmol/mmol (women). Percentiles 10 and 90 for urinary hydroxyproline are 0.006 and 0.024 mmol/mmol (male) and 0.010 and 0.025 mmol/mmol (women).

Treatment of bone metastases from breast cancer and myeloma with pamidronate

28 patients with progressing painful bone metastases (18 breast cancer, 9 myeloma and 1 low grade lymphoma) received pamidronate 60 mg by 24 h continuous infusion for at least 2 courses (range 2-12). In patients urinary calcium and hydroxyproline excretion significantly decreased in relation to diminution of bone resorption. 9 of 18 breast cancer patients and 8 of 9 evaluable patients with myeloma had symptomatic improvement. Sclerotic areas of previously lytic lesions appeared in 8 breast cancer patients and in 1 myeloma patient. Transient fever developed in 1 patient and local phlebitis in 2. Among the 28 patients, 15 did not receive any anticancer treatment or have any change of the anticancer therapy during pamidronate administration. Of 7 with breast cancer, 4 had an improvement of symptoms and 4 sclerosis on radiographs. Impressive control of symptoms was the major feature of 8 myeloma patients, but only 1 had radiographic sclerosis.

Fast and effective treatment of malignant hypercalcemia. Combination of suppositories of calcitonin and a single infusion of 3-amino 1-hydroxypropylidene-1-bisphosphonate

Seventeen patients with malignant hypercalcemia were treated with a combination of a single dose of 3-amino 1-hydroxypropylidene-1-bisphosphonate (APD [also known as AHPrBP or palmidronate disodium]) and salmon calcitonin given as suppositories for 3 days. To assess whether such a combined short treatment has a significant benefit leading to earlier normalization of the plasma calcium level than does APD alone, 17 additional patients matched for the type of tumor, initial plasma calcium level, urinary hydroxyproline level, and the dose of APD served as controls. All patients receiving the combination of calcitonin and APD achieved normalization of the plasma calcium level within 9 days, with a decrease from 3.22 +/- 0.90 mmol/L (mean +/- SEM) to 2.29 +/- 0.03 mmol/L. In the group receiving APD alone, the plasma calcium level normalized in only 14 of 17 patients by day 9. In the group receiving calcitonin and APD, the drop in the plasma calcium level occurred more rapidly, and the plasma calcium values were lower from days 2 to 4. This advantage was explained by the calciuric effect of calcitonin, as reflected by a significant decrease in the notional setting of renal reabsorption of calcium, reaching 2.16 +/- 0.06 mmol/L compared with 2.34 +/- 0.06 mmol/L in the group receiving APD alone. There were no side effects of both treatments, in particular neither flushing nor nausea induced by the suppositories of calcitonin. Clinical Improvement occurred after 2 days in the group receiving the combined treatment. In conclusion, the combined treatment is rapidly effective and safe in the treatment of patients with hypercalcemia, particularly when the notional setting of renal tubular reabsorption of calcium is increased and a rapid correction of the plasma calcium level is needed.

[A single infusion of Pamidronate (APD) in Paget's disease of bone]

Bisphosphonates are strong inhibitors of bone resorption and have become the treatment of choice of Paget's disease of bone. Second generation compounds such as amino-hydroxypropylene bisphosphonate (Pamidronate or APD) have not been found to impair bone mineralization, but to induce sustained remission of Paget's disease after short or medium courses. Gastrointestinal side effects may limit compliance. Therefore, 11 patients with mild but symptomatic Paget's disease of bone were treated with APD administered as a single intravenous infusion of 60 mg over 24 hours. The follow-up, with clinical and biochemical evaluations, was between 6 months and one year. Clinical improvement and normalization of biochemical parameters were observed in all patients. On average, plasma alkaline phosphatase activity fell progressively and significantly from 256 +/- 29 U/l (means +/- SEM) to 97 +/- 6 U/l after 6 months and to 102 +/- 11 U/l after one year (normal less than 120 U/l). Urinary excretion of hydroxy-proline decreased within 7 days to normal (from 4.3 +/- 0.5 mumol/lGF to 1.7 +/- 0.2 mumol/lGF, normal less than 2.2). Thereafter it remained within the normal range until one year later (1.8 +/- 0.2 mumol/lGF after 6 months and 1.9 +/- 0.3 mumol/lGF after 1 year). Side effects were negligible, with only a transient increase in body temperature in 2 patients. When bone scintigraphy was repeated after 6 months it revealed a marked decrease in the activity of the disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of tumor-induced osteolysis by APD

Bisphosphonates, associated with rehydration, became the treatment of choice of malignant hypercalcemia when it became apparent that these compounds normalized plasma calcium in most cases within a few days and with almost no side effects, and that their effect was prolonged. Dichloromethylene bisphosphonate and aminobisphosphonate, especially APD, were shown to inhibit bone resorption with no noticeable inhibition of bone formation, and were highly effective in the long-term treatment of Paget's disease. APD was used in almost 300 patients with malignant hypercalcemia published in the literature and has been used in the medical clinic at Lausanne for several years. When given to 14 patients with malignant hypercalcemia at the dose of 25 mg/day until plasma calcium became normal for two consecutive days, APD had to be given for 4-11 days, severe hypercalcemia needing longer treatment than mild hypercalcemia (Adami et al. 1982). When given for a fixed period of 6 days, again plasma calcium normalized in all patients, whether APD was given i.v. (30 mg/day, ten patients) or orally (1200 mg/day, ten patients) (Adami et al. 1985). Further shortening of the treatment to one single infusion given over 24 h did not decrease the efficacy, as long as high enough doses were given (Blomqvist 1986). For severe hypercalcemia of above 3.5 mmol/liter 60-90 mg had to be given, while 30-45 mg was sufficient in milder cases (Body 1984). Otherwise, mild, transient, and asymptomatic hypocalcemia could occur. Normalization of plasma calcium went along with clinical improvement, sometimes even with correction of coma. Renal function was improved, even when the initial plasma creatinine levels were up to twice normal. Hypercalcemia could reoccur, but the duration of the effect of APD (1 week to several months) depended among other things on the dose administered. The decrease in plasma calcium was accompanied by a decrease in urinary calcium and hydroxyproline, both showing inhibition of bone resorption. In the case of recurrency, the treatment could be repeated with almost unaltered efficacy, except in end-stage cancer disease. When given to 13 normocalcemic patients with bone metastases from breast cancer, hydroxyproline and urinary calcium again decreased. Bone pains and radiologic signs of metastatic bone resorption also showed significant improvement, although these latter effects could also be explained by the antitumoral treatment, in this uncontrolled open trial.(ABSTRACT TRUNCATED AT 400 WORDS)

A single infusion of the bisphosphonate AHPrBP (APD) as treatment of Paget's disease of bone

PURPOSE

Disabling pain, skeletal deformity, or risk of joint involvement characterize Paget's disease of bone. Because the disease often affects the elderly, for whom compliance is a problem, we investigated therapy with a single intravenous infusion of amino-hydroxypropylidene bisphosphonate (AHPrBP, previously APD).

PATIENTS AND METHODS

Eleven patients with mild but symptomatic Paget's disease and one patient with very severe disease were treated with AHPrBP administered as a single intravenous infusion of 60 mg over 24 hours. Follow-up with clinical and biochemical evaluations was performed over six months for all patients, and over one year for seven patients.

RESULTS

Clinical improvement and normalization of biochemical parameters were observed in all patients except one with extremely severe disease. On average, plasma alkaline phosphatase activity fell progressively and significantly from 256 +/- 29 U/liter (mean +/- SEM) to 97 +/- 6 U/liter after six months, and to 102 +/- 11 U/liter after one year (normal: less than 120 U/liter). Urinary excretion of hydroxyproline decreased within seven days to normal (from 4.3 +/- 0.5 mumol/liter of glomerular filtrate [lGF] to 1.7 +/- 0.2 mumol/lGF; normal: 2.2 mumol/lGF). Thereafter, it remained within the normal range until one year (1.8 +/- 0.2 mumol/lGF after six months and 1.9 +/- 0.3 mumol/lGF after one year). Side effects were negligible. Two patients noted only a transient increase in body temperature. When bone scintigraphy was repeated after six months, it revealed a marked decrease of the activity of the disease.

CONCLUSION

Due to the important and sustained inhibition of bone resorption induced by AHPrBP, a single infusion of 60 mg of the bisphosphonate leads to a rapid decline in activity and a long-standing remission of moderate Paget's disease, without significant side effects.

Oxidative and non-oxidative glucose metabolism in non-obese type 2 (non-insulin-dependent) diabetic patients

Insulin resistance is a common feature of Type 2 (non-insulin-dependent) diabetes mellitus. This defect in insulin-mediated glucose metabolism could result from a defect in either glucose oxidation or non-oxidative glucose disposal. To examine this question, euglycaemic insulin clamp studies were performed in 16 normal weight Type 2 and 11 age-matched control subjects. In Type 2 diabetic patients the fasting plasma glucose concentration, 8.39 +/- 0.50 mmol/l, was allowed to decline (over 54 +/- 6 min) to 5.33 +/- 0.11 mmol/l before starting the insulin clamp. Total body glucose uptake was significantly decreased in Type 2 diabetic patients vs control subjects (148 +/- 15 vs 264 +/- 25 mg/min.m2, p less than 0.001). Both total glucose oxidation (59 +/- 6 vs 89 +/- 6 mg/min.m2, p less than 0.005) and non-oxidative glucose disposal (89 +/- 15 vs 179 +/- 24 mg/min.m2, p less than 0.005) were significantly reduced in the Type 2 diabetic patients. Basal glucose oxidation was also reduced in the Type 2 diabetic patients (22 +/- 3 vs 38 +/- 5 mg/min.m2, p less than 0.01). In conclusion, during the postabsorptive state and under conditions of euglycaemic hyperinsulinaemia, impairment of glucose oxidation and non-oxidative glucose disposal both contribute to the insulin resistance observed in normal weight Type 2 diabetic patients. Since lipid oxidation was normal in this group of diabetic patients, excessive non-esterified fatty acid oxidation cannot explain the defects in glucose disposal.

Dose-response in the treatment of hypercalcemia of malignancy by a single infusion of the bisphosphonate AHPrBP

Fifty-two patients with malignant hypercalcemia were treated with a single dose of 3-amino-1-hydroxypropylidene-1,1- bisphosphonate (AHPrBP, previously APD), a potent inhibitor of osteoclast-mediated bone resorption. In order to establish a dose-response in humans, patients were divided into four groups receiving 30 mg, 45 mg, 60 mg, or 90 mg, respectively, as a 24-hour infusion. Initial plasma calcium was similar in all groups, except in the group receiving 90 mg, of which some patients had higher initial values. All patients responded to AHPrBP with a rapid decrease of plasma calcium concentration from 3.47 +/- 0.10 mmol/L at day 0 to 2.43 +/- 0.06 at day 6 (P less than .001). Plasma calcium became normal within four to six days in 43 patients. Eight of the nine patients whose calcium did not become normal were in the low-dose (30 and 45 mg of AHPrBP) groups. Slight and asymptomatic hypocalcemia occurred in only tow of the 26 patients in the low-dose groups, but in six of the 26 patients in the high-dose groups. A follow-up study in 40 patients showed that hypercalcemia recurred within 1 month in five of ten patients in the group receiving 30 mg, in three of ten patients in the group receiving 45 mg, and in one of 20 patients in the groups receiving 60 and 90 mg, whereas mortality was almost identical in all four groups. In all groups, plasma phosphate, plasma creatinine, urinary calcium, and hydroxyproline excretion decreased significantly. In conclusion, when administered as a single-day infusion in the treatment of tumor hypercalcemia, AHPrBP leads to a dose-dependent decrease in plasma calcium. To prevent transient hypocalcemia and early relapse, the optimal dose should be adapted to the degree of severity of hypercalcemia.

[Treatment of neoplastic hypercalcemia using single-infusion diphosphonate]

40 patients with malignant hypercalcemia were treated with a single dose of APD, a potent inhibitor of osteoclast-mediated bone resorption. In order to establish a dose response in man, the patients were divided into four groups receiving 30, 45, 60 or 90 mg respectively as 24-hour infusion. Initial plasma calcium was similar in all groups except that receiving 90 mg, some of whose patients had higher initial values. All patients responded to APD with a rapid decrease of plasma calcium concentration from 3.44 +/- 0.10 mmol/l at day 0 to 2.33 +/- 0.06 at day 6, p less than 0.001). Plasma calcium became normal within 4 to 6 days in all patients but 6, all from the group receiving the low doses of APD (30 or 45 mg). Slight and asymptomatic hypocalcemia occurred in only 2 patients of the low dose groups, but in 6 of the high dose groups. A follow-up study in 40 patients showed that hypercalcemia recurred within 2 months in 6 patients of group 30 mg, in 5 patients of group 45 mg, in 1 patient of group 60 mg and in 2 patients of group 90 mg, whereas mortality was almost identical in the 4 groups. When retreated with a single dose of APD, all patients again showed normalization of calcemia. In all groups plasma phosphate, plasma creatinine and urinary calcium excretion decreased significantly. Clinical improvement was observed in all patients, with minimal side effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Effectiveness of salmon calcitonin administered as suppositories in tumor-induced hypercalcemia

Although calcitonin is a natural, nontoxic, and rapid inhibitor of bone resorption, its use in the treatment of hypercalcemia is limited because of its transient efficacy and the need for repeated parenteral administration. In normal subjects, suppositories of calcitonin have been shown to be biologically active. Peak plasma concentrations of salmon calcitonin after rectal administration in six normal subjects were similar to those measured after parenteral administration. To evaluate the efficacy of calcitonin suppositories in disease states, 10 patients with moderate hypercalcemia due to malignancy were treated with salmon calcitonin, administered as suppositories containing 300 MRC units, three times a day for seven days. The mean plasma calcium level decreased significantly from 2.96 +/- 0.09 mmol/liter to 2.57 +/- 0.09 after one week (p less than 0.005) and rose again after discontinuation of treatment to 2.86 +/- 0.09 mmol/liter one week later. Urinary calcium and hydroxyproline values decreased during treatment and rose after discontinuation of treatment. The plasma calcium level decreased rapidly in six patients, becoming normal in five; three patients showed only a partial response, and one patient had no response at all. No side effects were observed, and clinical improvement was noted in nine of the 10 patients. Little or no response was observed in patients with extremely high urinary calcium or, to a lesser extent, high hydroxyproline excretion. There was a significant negative correlation between the maximal decrease in plasma calcium concentration and initial urinary calcium excretion (r -0.78, p less than 0.01). Thus, salmon calcitonin administered by the rectal route appears to be an easy, safe, and effective treatment of moderate hypercalcemia without apparent side effects.