Bone mineral density at menopause does not predict breast cancer incidence

In this prospective study in 2,137 perimenopausal and early postmenopausal women who were followed over a 13.1-year period of time, we observed no association between bone mineral density measured at the beginning of menopause and the subsequent risk of breast cancer.

INTRODUCTION

This study aimed to investigate the relationship between BMD and the risk of breast cancer (BC) in young postmenopausal women.

METHODS

As part of a clinical research program, 2,137 women who were perimenopausal or within their 5 first postmenopausal years were scanned between 1988-1990 and reviewed on average 13.1 years after their initial examination. Ninety-eight incident BC cases were recorded throughout the follow-up.

RESULTS

Women with incident BC significantly differed from those who had never had BC with regard to age at menarche, age of birth of 1st child, familial history of BC and postmenopausal hormone therapy (PHT) use. There was no significant difference between the two groups for baseline DXA of the spine. There was a trend for BC cases for having lower femoral neck BMD compared to women without BC. However, women with low BMD were more likely to have taken PHT by the end of the study. In Cox multivariate analyses the relationship between BC risk and femoral neck BMD no longer existed.

CONCLUSIONS

There was no relationship between BMD measured within the first postmenopausal years and the risk of BC, which makes unlikely the possibility of using BMD as a predictor factor for BC in early postmenopausal women.

Frailty, osteoporosis and hip fracture: causes, consequences and therapeutic perspectives

OBJECTIVE

The aim of this review of the literature is to report the factors which both contribute to the frailty syndrome and increase hip fracture risk in the elderly. This work is the fruit of common reflection by geriatricians, endocrinologists, gynecologists and rheumatologists, and seeks to stress the importance of detection and management of the various components of frailty in elderly subjects who are followed and treated for osteoporosis. It also sets out to heighten awareness of the need for management of osteoporosis in the frail elderly.

DESIGN

The current literature on frailty and its links with hip fracture was reviewed and discussed by the group.

RESULTS

The factors and mechanisms which are common to both osteoporosis and frailty (falls, weight loss, sarcopenia, low physical activity, cognitive decline, depression, hormones such as testosterone, estrogens, insulin-like growth factor-I (IGF-I), growth hormone (GH), vitamin D and pro-inflammatory cytokines) were identified. The obstacles to access to diagnosis and treatment of osteoporosis in the frail elderly population and common therapeutic pathways for osteoporosis and frailty were discussed.

CONCLUSION

Future research including frail subjects would improve our understanding of how management of frailty can can contribute to lower the incidence of fractures. In parallel, more systematic management of osteoporosis should reduce the risk of becoming frail in the elderly population.

[Raloxifene in postmenopausal women]

Since the diffusion of the WHI's trial and MWS results, which reported a negative risk/benefit balance of hormone therapy, the management of postmenopausal women has deeply changed over the last 2-3 years. In particular, for the prevention of osteoporosis, the use of other efficient agents tends now to be more widely recommended rather than estrogens. The SERMs with raloxifene are new molecules that have estrogen agonist effects on bone and estrogen antagonist or neutral effects on endometrial and breast tissue. The efficacy of raloxifene to inhibit postmenopausal bone loss as well as to reduce the incidence of vertebral fractures has been demonstrated in women at high risk for osteoporosis through a large randomized placebo-controlled trial involving several thousands of postmenopausal women (MORE trial). Furthermore, the extraskeletal effects of raloxifene might represent an advantage for a global management approach of postmenopausal women, although to date, its exclusive indication is namely the prevention of osteoporosis. However, the estrogen antagonist effects of raloxifene on breast tissue as well as its good safety profile with regard to both the endometrium and the risk of heart diseases are likely to make raloxifene of particular interest for women around the age of 60 years old. Adverse events associated with raloxifene only included an increase in the absolute risk of venous thromboembolism in a comparable manner as with estrogen therapy. Also, its lack of efficacy in reducing hot flushes or preventing vaginal dryness may limit its use in young symptomatic postmenopausal women. Also, its lack of reimbursement in women with no prior fragility fracture must be taken into account.

Alendronate produces greater effects than raloxifene on bone density and bone turnover in postmenopausal women with low bone density: results of EFFECT (Efficacy of FOSAMAX versus EVISTA Comparison Trial) International

OBJECTIVES

Alendronate and raloxifene are antiresorptive agents with different mechanisms of action, each used to treat osteoporosis in postmenopausal women. This study was undertaken to compare the efficacy and tolerability of alendronate to raloxifene in postmenopausal women with low-bone density.

DESIGN

Randomized, double-masked, double-dummy multicentre international study.

SETTING

Clinical trial centres in Europe, South America and Asia-Pacific.

SUBJECTS

A total of 487 postmenopausal women with low bone density, based on bone mineral density (BMD) of the lumbar spine or hip (T-score < or =-2.0). Interventions. Patients received either alendronate 70 mg once weekly and daily placebo identical to raloxifene or raloxifene 60 mg daily and weekly placebo identical to alendronate for 12 months.

MAIN OUTCOME MEASURES

Evaluations included BMD of the lumbar spine and hip and markers of bone turnover at 6 and 12 months and adverse event reporting.

RESULTS

Alendronate demonstrated substantially greater increases in BMD than raloxifene at both lumbar spine and hip sites at 12 months. Lumbar spine BMD increased 4.8% with alendronate vs. 2.2% with raloxifene (P < 0.001). The increase in total hip BMD was 2.3% with alendronate vs. 0.8% with raloxifene (P < 0.001). Reductions in bone turnover were significantly larger with alendronate than raloxifene. Overall tolerability was similar, however, the proportion of patients reporting vasomotor events was significantly higher with raloxifene (9.5%) than with alendronate (3.7%, P = 0.010). The proportion of patients reporting gastrointestinal events was similar between groups.

CONCLUSION

In postmenopausal women with low bone density, improvements in BMD and markers of bone turnover were substantially greater during treatment with alendronate compared to raloxifene.

[Diagnostic value of classical neurophysiologic profile in various phenotypes of hereditary, pressure-sensitive neuropathies]

PURPOSE

We looked for electrodiagnostic features that raise suspicion of hereditary neuropathy with liability to pressure palsies (HNPP).

METHOD

A retrospective review of eight cases with confirmed histologic (one case) or chromosome 17 deletion (seven cases) analysis was performed.

RESULTS

Autosomal dominant disease was present in 63% of the patients, 75% being men. Mean age at examination and at first symptom was 27 and 22 years respectively. Five patients have one or more acute nerve palsies, without residual deficit, but one presented sensory symptoms in internal saphena territory. Three patients had others phenotypes: a man presented with four episodes of facial palsy and one woman was asymptomatic; another patient with diabetes mellitus presented an associated chronic sensorimotor polyneuropathy. In agreement with other studies of HNPP we found in most patients a diffuse increase in distal motor latence, contrasting with normal or moderately decreased motor nerve conduction velocity, multiple electrophysiologic entrapment and diffuse reduction in sensory nerve action potential and/or velocity. However, this electrophysiological pattern was incomplete or masked in HNPP with cranial nerves palsies, in asymptomatic form of HNPP or in HNPP associated with polyneuropathy.

CONCLUSION

These data confirm the clinical phenotypic heterogeneity of the 17p11.2 deletion and highlight the limits of the classic electrophysiological pattern in asymptomatic HNPP or associated with uncommon clinical features.

[Muscular exercise intolerance syndrome in Becker muscular dystrophy]

OBJECTIVE

To determine whether exertional muscle pain syndrome (EMP) is a benign phenotype or an early stage of Becker-type muscular dystrophy (BMD).

METHODS

Muscle dystrophin analysis led to the diagnosis of BMD in 6 patients complaining of EMP.

RESULTS

Three patients had a history of X-linked inheritance and age at clinical onset was 4 to 11 years in five, and one patient had a later onset aged 23. Pseudohypertrophy of the calf muscles was absent in one patient, but all had experienced mild (5/6) pelvic weakness and (or) atrophy one to 17 years after the onset. High serum CK level was present (X 14). Normal anti-dystrophin immunostaining in two cases did not rule out the diagnosis that was only made made by Western blot analysis or genetic studies. All exhibited in-frame deletions (exons 45-48) within the dystrophin gene.

CONCLUSION

The 36 patients with BMD-EMP analysed in the literature, exhibited different deletions and no worsening in 66.7% of cases. Western blot was more precise than immunolabelling with 96.8% positivity versus 70.5%. Dystrophin analysis by Western blot and (or) DNA analysis should be included in the evaluation of patients with EMP syndrome without deficient muscle energy metabolism, particularly those with pseudohypertrophy of the calf muscles or high serum CK levels.

[Neuritic leprosy disclosed by reversal reaction]

We report a case of neuritic borderline tuberculoid leprosy with lingering insidious growth disclosed by a brutal reversal reaction. Inflammatory polyarthralgia and sensory and motor loss in the median and ulnar territories, without skin lesions, suggested vasculitis. A few weeks later, inflammatory skin lesions developed leading to the diagnosis of biopsy proven leprosy. Leprosy should be considered as a possible diagnosis in patients with multineuritis, especially when associated with rheumatic or cutaneous manifestations. Early skin biopsy in neuritic leprosy is discussed.

[Transformation of mycosis fungoides to pleomorphic T-cell lymphoma and central nervous system involvement]

INTRODUCTION

Although mycosis fungoides is a malignant T-cell lymphoma involving mainly the skin, neurological complications are possible, with a poor prognosis.

EXEGESIS

A 59-year-old man, treated for mycosis fungoides with transformation to a pleomorphic T-cell lymphoma for 1 year, was seen for mental status changes with confusion. A brain parenchyma localisation was found.

CONCLUSION

This observation emphasizes the exceptional neurological tropism in the patients with mycosis fungoides. A transformation to a more aggressive cutaneous T-cell lymphoma seems necessary to induce a central nervous system involvement.

[Multiple intracranial and intraspinal meningiomas successively discovered in the absence of neurofibromatosis: 2 cases]

Multiple meningiomas in different neuroaxial compartments are quite rare. We describe the case of a 44-year-old woman who developed three intracranial meningiomas and 8 years later a T3 dorsal meningioma. Histologically, the frontal and dorsal tumors appeared as benign psammomatouss meningiomas. Both tumors were removed successfully. The second patient was a 31-year-old woman who developed right benign fronto-parietal transitional meningioma. She presented local and spheno-orbital recurrences, then a lombo-sacral lesion. The histological picture worsened from benign to malignant with multiple recurrences. Several mechanisms could account for multiple meningiomas. Such meningiomas could arise from a single primary tumor via subarachnoidal spread of a benign or malignant nature. Alternatively, they could be atypical forms of neurofibromatosis type 2 or tumors with a multifocal origin.

[Anterior compartment syndrome of the forearm caused by exercise: unusual cause of recurrent episodes of acute effort rhabdomyolysis]

INTRODUCTION

An effort-related compartmental syndrome is well known in the leg, but may be present infrequently, acutely or chronically in the anterior compartment of the forearm.

EXEGESIS

We report a case of a 32-year-old man who presented four times after climbing exercises a bilateral compartment of the forearm, unusual because of the observation of rhabdomyolysis, but without irreversible damage. Clinical information and follow-up on two acute and 14 chronic cases were reexamined, showing a homogenous presentation. He refused fasciotomy because he stopped athletic activities. Measurement of intramuscular pressure after exertion was useful for diagnosis.

CONCLUSION

A local effort-related pain must call to mind a chronic compartment syndrome of the forearm, which may risk incurring the acute form, with irreversible lesions of muscle and nerve, and possibly renal failure because of rhabdomyolysis.

[Recurrent rhabdomyolysis revealing chronic exertional compartment syndrome of the biceps]

OBJECTIVE AND PATIENT: To report, an uncommon case of recurrent effort-related biceps compartment syndrome induced by strengthening exercises (body building) in a thirty-years-old white man.

DISCUSSION-CONCLUSION

compartment syndrome is typically observed in the lower leg or in the forearm with pain, muscle tightness, cramp-like feeling during exertion. The involvement of the biceps was only described after traumatisms. Patient was initially thought to have metabolic myopathy because acute episodes of exercise induced myalgia and elevated serum CK. Tissue pressure monitoring prior and after a standard exercise test is helpful for diagnosing the recurrent form. The only alternative to fasciotomy is to stop sports activities.

Ability of peripheral DXA measurements of the forearm to predict low axial bone mineral density at menopause

The aim of this study was to evaluate the ability of peripheral dual-energy X-ray absorptiometry (pDXA) measurement of the forearm to predict low axial bone mineral density (BMD) as defined according to the WHO classification. Two hundred and thirty-four healthy women aged 45-60 years were investigated. BMD was measured at the proximal and distal radius + ulna by pDXA and at the lumbar spine and femoral neck by DXA. There was a significant but moderate correlation between peripheral and axial BMD measurements, with r values ranging from 0.4 to 0.6 (SEE: 13.5-17%). The cutoff values for the proximal and distal radius BMD that allow the identification with 95% sensitivity of postmenopausal women with either a lumbar spine or femoral neck T-score < -1, corresponded to a T-score of +0.5 (proximal radius) and +1 (distal radius). More than 90% of the whole population had a peripheral T-score below these thresholds. Using an axial T-score < or = -2.5 as the definition of abnormality reduced to 48% (proximal radius) to 66% (distal radius) the number of women who would have required DXA axial measurements (i.e., with a pDXA T-score below the cutoff value of -0.7). Of the 33 women (14%) with a proximal radius T-score < or = -2.5 (osteoporosis), only 1 had a lumbar spine and femoral neck T-score > or = -1 (normal). Conversely, of the 50% (proximal radius) to 65% (distal radius) of the women with normal forearm measurement, 5% (proximal radius) to 9% (distal radius) were found to be osteoporotic and an additional 57% (proximal radius) to 59% (distal radius) could be classified as osteopenic (T-score between -1 and -2.5) at either the lumbar spine or femoral neck. In conclusion, use of pDXA forearm measurement as a prescreening tool in early postmenopausal women should allow the direct identification of about 50% of the women with no axial osteoporosis. However, this study highlights the difficulties in using a unique T-score that could be applied to different sites to diagnose osteoporosis.

Withdrawal of hormone replacement therapy is associated with significant vertebral bone loss in postmenopausal women

This study aimed to assess the changes in vertebral bone mineral density (BMD) after cessation of hormone replacement therapy (HRT) in postmenopausal women who had been treated on a long-term basis. Fifty healthy postmenopausal women who had been followed both during the course of HRT and after cessation of treatment in our menopause clinic were included in this study. All women had started HRT within the first 3 years after the postmenopause and had received HRT (either 1.5 mg/day of 17 beta-estradiol given percutaneously or 50 micrograms/day of 17 beta-estradiol given as a transdermal patch, combined in all women with natural progesterone or a 19-norprogesterone derivative) for a mean 5 +/- 2.4 years. In all women, vertebral BMD was assessed during the course of HRT up to the last 6 months before estrogen withdrawal, then at least once within the first 18 months after cessation of treatment. Of the initial population, 30 women were additionally reviewed later on and up to 8 years after cessation of treatment (mean duration of follow-up for the whole population: 3.9 +/- 1.7 years). Rates of changes in vertebral BMD were compared with those determined in a group of healthy untreated women who had been followed within the first years of postmenopause during the same time period as the study population. In the study group, bone loss was found to accelerate within the first 2 years after HRT withdrawal and the annual rate of loss was identical to that which occurs within the first 2 years of postmenopause in untreated women (-1.64% +/- 1.3% vs -1.52 +/- 0.9%, NS). Beyond this first 2-year time period, the annual rate of bone loss decreased as a function of time following cessation of treatment, as was observed following the menopause in untreated women (between 3 and 5 years: -0.83% + 1.35% in the study group vs -0.70% +/- 0.8% in the control group, NS). On average, 3 years after cessation of HRT mean vertebral BMD when expressed as a Z-score was significantly higher (-0.13 vs -0.89, p < 0.01) than at baseline, before HRT was started, which suggested a lasting beneficial effect on bone mass. However, even though our findings do not support the hypothesis that bone loss might continue to be accelerated several years after cessation of treatment we cannot fully address the question as to whether any residual benefit on bone mass over a longer period of time may be observed. In conclusion, the pattern of bone loss observed after cessation of estrogen therapy was found to be comparable to that which occurs in younger women within the first years after the menopause. Such a pattern needs to be kept in mind when the decision to stop HRT is taken, especially in women who were given HRT to prevent osteoporosis. The issue of assessing their risk of fracture several years after cessation of treatment thus needs to be addressed.

Effect of hormone replacement therapy on age-related increase in carotid artery intima-media thickness in postmenopausal women

The aim of this study was to determine the changes in carotid artery intima-media thickness as measured by B-mode ultrasound in postmenopausal women receiving hormone replacement therapy (HRT) or not. One hundred and fifty-nine healthy postmenopausal women aged 45-65 years were recruited from our menopause clinic. All the selected women were free of cardio-vascular diseases and had no cardio-vascular risk factors. None of the women were receiving lipid-lowering or antihypertensive drugs. Because carotid artery intima-media thickness was shown to be strongly and positively correlated with age in women aged 55 years and older but not before, women were divided into four groups according to age (<55 vs. > or =55 years) and use of HRT (current users vs. never users). All the treated women received non-oral 17beta-estradiol with a non-androgenic progestin and had started HRT within the first year after menopause. Scanning of the right common carotid artery was performed with a B-mode ultrasound imager and thickness of the intima-media complex as well as luminal diameter of the artery were determined using an automated computerized procedure. Within each age group (i.e. <55 or > or =55 years), women had comparable demographic characteristics and only differed by HRT use. Long-term treated women had significantly lower total cholesterol levels than untreated women (P=0.005). Triglycerides, low-density lipids (LDL)-cholesterol and high-density lipids (HDL)-cholesterol levels, systolic and diastolic blood pressure were not significantly different between users and non-users. In women <55 years, no significant difference in carotid intima-media thickness was found between current users (mean 2.5+/-1.4 years) and non users. In older women, the mean values of carotid intima-media thickness were significantly smaller in current users (mean 6.9+/-3.3 years) than in never treated women: 0.50+/-0.05 versus 0.56+/-0.07 mm, P<0.0001. Carotid artery intima-media thickness was significantly correlated to age in never users (r=0.5, P<0.0001) but not in women who were currently receiving HRT (r=0.2, ns). These findings suggest an apparent protective effect of long-term HRT on age-related thickening of the intima-media of the right common carotid artery. This may contribute to explain the apparent cardio-protective effect of HRT after the menopause.

[Mitochondrial diabetes complicated by or associated with "MELAS" syndrome?]

We report the case of fifty-two year-old mentally deficient female who presented with diabetes mellitus, deafness, stroke-like episodes, cardiomyopathy, and macular pattern dystrophy of the retina. Her brain exhibited calcification within basal ganglia, lactacidaemia was not increased. Although her skeletal muscles had never been clinically impaired, a quadriceps biopsy led to the diagnosis of mitochondrial disease because it exhibited ragged red fibers and heteroplasmic point-mutation at position 3243 of the mitochondrial DNA, although not any detectable respiratory chain complex deficiency was found. The mutant percentage in muscle was 70 p.100 and 5 to 10 p.100 in leukocytes. The question of whether a diabetic microangiopathy may be responsible stroke-like episodes is discussed. We suggest it was rather a complicated form of diabetes-deafness than a incomplete MELAS syndrome associated with mitochondrial diabetes.

[Estrogens and selective estrogen receptor modulators in the treatment of osteoporosis]

Estrogen deficiency is the major determinant of bone loss, not only in the first years postmenopause, but also throughout the entire life and in the elderly. Major progress in the knowledge of cellular actions of estrogens has been made leading to a better understanding of the underlying mechanisms of different estrogen-deficiency related diseases such as osteoporosis, atherosclerosis and also maybe cerebral aging. Estrogen replacement therapy remains the first choice treatment in the prevention of postmenopausal osteoporosis, but the continuous aging process of the female population raises the question of a better strategy of action in a more efficient prevention of hip fractures. Moreover, the potential gynecological effects of estrogens are likely to limit their indications or long-term use. The development of new compounds, called SERMs (selective estrogen receptor modulators), with both agonist and antagonist estrogen actions, in particular with no negative effects on the uterus and the breast opens new therapeutical insights into the prevention of postmenopausal osteoporosis.

Risedronate reverses bone loss in postmenopausal women with low bone mass: results from a multinational, double-blind, placebo-controlled trial. BMD-MN Study Group

Our objective was to investigate the efficacy and tolerability of risedronate in postmenopausal women with low bone mass. Women with a mean lumbar spine T-score of -2 or less (n = 543) received 24 months of placebo or risedronate (2.5 or 5 mg/day). All received calcium (1 g/day). The principal outcome measures were bone mineral density (BMD) at the lumbar spine, femoral neck, and femoral trochanter. At 24 months, lumbar spine BMD increased from baseline by 4% with 5 mg risedronate and 1.4% in the 2.5-mg group, compared with no change with placebo. Efficacy was similar in women who were less than 5 yr and more than 5 yr postmenopausal. At 24 months, risedronate (5 mg) had also increased BMD at the femoral neck and trochanter, whereas BMD decreased in the placebo group. BMD increases were seen at all three sites with risedronate (5 mg) after only 6 months of therapy. Risedronate was well tolerated; upper gastrointestinal adverse events were similar to placebo. We conclude that risedronate (5 mg) increases BMD rapidly and effectively and is well tolerated in postmenopausal women with low bone mass, regardless of time since menopause.

[Retroclival hematoma in a patient taking oral anticoagulants]

Retroclival hematoma associated with anticoagulation. We report a case of retroclival hematoma associated with anticoagulant therapy in a 78-year-old-woman, who presented with an isolated left external ophthalmoplegia. The role of the anticoagulant therapy is discussed. There was a spontaneous neurological resolution.

Accuracy and precision of in vivo bone mineral measurements in sheep using dual-energy X-ray absorptiometry

We evaluated the precision and accuracy of in vivo measurements of spine bone mineral density (BMD) and bone mineral content (BMC) in five ewes using dual-energy X-ray absorptiometry (DXA, Lunar DPX-L). The short-term in vivo reproducibility expressed as the coefficient of variation (CV) varied from 0.9 to 1.6% for spine BMD and from 1 to 3.1% for spine BMC. The ex vivo measurements, performed in 20 cm of water to simulate soft tissue thickness, correlated closely with the in vivo measurements, yielding an r value of 0.98 and 0.97 for spine BMD and BMC, respectively. The accuracy was determined by comparing the total BMC of each vertebra measured in vivo with the corresponding ash weight. The correlation coefficient between the two measurements was r = 0.98, with an accuracy error of 5.6%. We concluded that the DXA allows a precise and accurate measurement of spine bone mineral in live ewes using the methodology designed for humans.

[Primary intramedullary spinal cord lymphoma in HIV patients. MRI aspects]

We report a case of an immunocompetent man who developed primary spinal intramedullary malignant lymphoma. This condition occurs in about 0.9 p. 100 of primary central nervous system non-Hodgkin lymphomas in non-AIDS patients. Magnetic resonance imaging was nonspecific but suggestive. Like the brain localization, prognosis is poor. Because of the high frequency of recurrence, usually confined to the central nervous system with neuraxis dissemination, treatment must be delivered to the entire neuraxis. But more effective treatment strategies with radiotherapy-chemotherapy combinations will be needed. Feasibility and toxicity patterns remain to be determined.

[Cerebral intravascular lymphoma during T CD4+ idiopathic lymphopenia syndrome]

BACKGROUND

Intravascular lymphoma is a proliferation of lymphoid cells, usually B cells, in small vessels, predominantly in the nervous system and skin.

CASE REPORT

We report a case of a man with a 3-year history of lymphopenia with no detectable etiology (all viral causes were ruled out) who developed intravascular lymphoma in the cerebral vessels.

DISCUSSION

This case was particular as the patient had idiopathic CD4+ lymphopenia. It points out the probable role of immunodepression in the development of lymphomas, particularly in endovascular localizations.

[Hormone replacement therapy in the prevention of osteoporosis. Evolution of therapeutic methods]

ESTABLISHED FACTS: Many studies have evidenced that hormone replacement therapy can help prevent post-menopausal osteoporosis and osteoporotic fractures in menopaused women. Thanks to recent advances in pharmacology, hormone replacement therapy can now closely mimic ovarian physiology and thus eliminate most of the contraindications related to metabolic disorders. UNRESOLVED QUESTIONS: The need for prolonged treatment to reach optimal efficacy raises the problems of safety and compliance. This is particularly true for the prevention of fractures of the femoral neck which usually occur in older women, suggesting it could be useful to revisit the estrogen strategy. NEW COMPOUNDS: The action of selective estrogen receptor modulators (SERM) depends on the target organ. They have an estrogen agonist effect on bone and lipid metabolism but no such effect on the uterus. SERMs could offer new therapeutic opportunities for the prevention of post-menopausal osteoporosis.

Bone density reduction in various measurement sites in men and women with osteoporotic fractures of spine and hip: the European quantitation of osteoporosis study

We have measured bone mineral density (BMD) using dual X-ray absorptiometry (DXA) of the spine and hip, spinal quantitative computed tomography (QCTspi), and peripheral radial quantitative computed tomography (pQCTrad) in 334 spine and 51 hip fracture patients. The standardized hip and spine BMD for each patient was calculated and compared with the combined reference ranges published previously, each densitometer having been cross-calibrated with the prototype European Spine Phantom (ESPp) or the European Forearm Phantom (EFP). Male and female fracture cases had similar BMD values after adjusting for body size, where appropriate. This suggests that the relationship between bone density (mass per unit volume) and fracture risk is similar between men and women. However, compared with age-matched controls, mean decreases in BMD ranged from 0.78 SD units (women with hip fracture, DXAspi) to 2.57 SD units (men with spine fractures, QCTspi). The proportion of spine and hip fracture patients falling below the cutoff for osteoporosis (T-score <-2.5 SD) proposed by the World Health Organization (WHO) study group varied according to different BMD measurement procedures (range 18-94%). This finding suggests that the WHO definition requires different thresholds when used with non-DXA BMD measurement techniques. Receiver operator characteristic (ROC) analysis was used to compare measurement techniques for their ability to discriminate between cases and controls. Among DXA sites, the proximal femur was preferred when evaluating generalized bone loss, particularly in elderly people. An additional spinal BMD measurement may add clinical value if spine fracture risk assessment has a high priority. Both axial and peripheral QCT techniques performed comparably to DXA in spinal osteoporosis, so investigators and clinicians may use any of the three technologies with similar degrees of confidence for the diagnosis of generalized or site-specific bone loss providing straightforward clinical guidelines are followed.

Coronary heart disease risk factors and menopause: a study in 1684 French women

This study aimed to assess the relationship between menopause and various risk factors for coronary heart diseases (CHD) in a large sample of French women aged 45 65 years. One thousand six hundred and eighty-four consecutive healthy women who received a systematic check-up in our Menopause Unit were included in this study. All the women answered a computer-assisted questionnaire which comprised 156 items, 72 questions being exclusively related to the identification of familial and personal cardio-vascular risk factors. Biological measurements were performed to evaluate lipid-lipoprotein profile and fasting glucose levels. Women, none of whom were treated with hormonal replacement therapy, were classified as postmenopausal according to the date of their last menses and levels of serum FSH and estradiol (n = 1200). Perimenopausal women were further subdivided into two subgroups according to the regularity of their menstrual cycles and FSH levels (early (n = 143) and late (n = 341) perimenopause). 12% (n = 205) of the women were currently receiving lipid-lowering drugs (84.4% postmenopausal vs. 15.6% perimenopausal). When all women were considered, menopause was associated with a higher prevalence of hypertension and hypercholesterolemia (serum total cholesterol level > 250 mg/dl + LDL cholesterol level > 160 mg/dl). This higher prevalence in postmenopausal women was also found when the analysis was restricted to women aged 45 55 years, which rather suggests an effect of menopause than of age. Of the women not receiving hypolipidemic treatments, postmenopausal women had significantly higher serum levels of total cholesterol, LDL , VLDL cholesterol, triglycerides and apolipoprotein B and lower levels of HDL cholesterol than perimenopausal women. Multivariate analysis indicated that these effects were independent of age, body mass index and years since menopause. The prevalence of other metabolic disturbances was much more lower. On average, perimenopausal women had significantly less CHD risk factors than postmenopausal women (P < 0.0001). Fifty-two per cent of the perimenopausal women had none of the risk factors studied as compared with 39% of the postmenopausal women (P < 0.0001). This study shows that menopause was associated with a higher prevalence of risk factors for CHD.

[Polyradicular lesion revealing ankylosing spondylarthritis]

INTRODUCTION

Radicular manifestations of ankylosing spondylitis are rare and observed in the course of long-term ankylosing spondylitis.

EXEGESIS

The case of a young man who presented with bilateral and multiple radicular involvement is reported. Neurological symptoms occur a few weeks before ankylosing spondylitis was diagnosed.

CONCLUSION

This suggests that nerve root lesions might take place during initial stages of the disease. The role of inflammatory changes in the region of the intervertebral foramina is discussed. Disease evolution is marked by relief of neurological disorders in response to anti-inflammatory treatment.

Risk factors for hip fracture in men from southern Europe: the MEDOS study. Mediterranean Osteoporosis Study

The aims of this study were to identify risk factors for hip fracture in men aged 50 years or more. We identified 730 men with hip fracture from 14 centers from Portugal, Spain, France, Italy, Greece and Turkey during the course of a prospective study of hip fracture incidence and 1132 age-stratified controls selected from the neighborhood or population registers. The questionnaire examined aspects of work, physical activity past and present, diseases and drugs, height, weight, indices of co-morbidity and consumption of tobacco, alcohol, calcium, coffee and tea. Significant risk factors identified by univariate analysis included low body mass index (BMI), low sunlight exposure, a low degree of recreational physical activity, low consumption of milk and cheese, and a poor mental score. Co-morbidity including sleep disturbances, loss of weight, impaired mental status and poor appetite were also significant risk factors. Previous stroke with hemiplegia, prior fragility fractures, senile dementia, alcoholism and gastrectomy were associated with significant risk, whereas osteoarthrosis, nephrolithiasis and myocardial infarction were associated with lower risks. Taking medications was not associated with a difference in risk apart from a protective effect with the use of analgesics independent of co-existing osteoarthrosis and an increased risk with the use of anti-epileptic agents. Of the potentially 'reversible' risk factors, BMI, leisure exercise, exposure to sunlight and consumption of tea and alcohol and tobacco remained independent risk factors after multivariate analysis, accounting for 54% of hip fractures. Excluding BMI, 46% of fractures could be explained on the basis of the risk factors sought. Of the remaining factors low exposure to sunlight and decreased physical activity accounted for the highest attributable risks (14% and 9% respectively). The use of risk factors to predict hip fractures had relatively low sensitivity and specificity (59.6% and 61.0% respectively). We conclude that lifestyle factors are associated with significant differences in the risk of hip fracture. Potentially remediable factors including a low degree of physical exercise and a low BMI account for a large component of the total risk.

[Myositis ossificans circumscripta and sequelae of muscular ischemia. 2 cases]

INTRODUCTION

Non-traumatic myositis ossificans circumscripta is a relatively rare, well defined entity. The pathogenic role of ischemia in its development is discussed.

EXEGESIS

We report two cases of myositis ossificans circumscripta that occurred in the hamstring muscle respectively 22 and 35 years after ischemic muscular injury in the same site. Clinical and radiologic informations and follow-up were reexamined, showing that patients are usually young and that the disease is equally distributed between both genders. Though the lesion may develop in various muscle, it is preferentially observed in proximal sites. Most patients have a history of localized pain or tenderness accompanied by swelling of the affected site. Following a 5- to 12-week increase, the soft-tissue mass is less sensitive and better defined. It may also resolve in less than 3 years.

CONCLUSION

Results of X rays, computerized tomography, MR imaging and biopsy are reviewed. Histologically, this lesion main feature is peripheral bone maturation within three areas. Mechanisms (traumatic or not) underlying these lesions are unknown. To our knowledge, only one published case would be comparable to ours. Proliferation followed by change in mesenchymal cells leading to heterotopic ossification must be regarded as a consequence of either ischemia or repeated micro-trauma occurring during muscle shortening.

Measurement of bone mineral density in mother-daughter pairs for evaluating the family influence on bone mass acquisition: a GRIO survey

The relative influence of genetic and environmental determinants on bone mass is still unclear. Using an original multicentric mode of recruitment, based on absorptiometry current practice, the hypothesis of a familial predisposition to low bone mineral content was assessed. The study was based on dual-energy X-ray absorptiometry (DXA) measurements of lumbar and femoral neck bone mineral density (BMD), using daughters of women with a low BMD (case mothers). These BMD values were compared with those of control daughters of women with a normal BMD. Case mothers (n = 72) aged 54.3 +/- 4.8 years were recruited on the basis of a questionnaire and a vertebral Z-score < -2 SD. Their healthy daughters of more than 20 years (n = 77) aged 28.2 +/- 4.9 years had their vertebral and femoral BMD Z-score determined. The control groups were composed of mothers aged 54.1 +/- 4.7 years, paired by age +/- 2 years to the case mothers, and of their daughters of more than 20 years old, aged 27.7 +/- 5.8 years. For daughters, a significant difference was found between the mean vertebral Z-scores (-0.82 +/- 1.08 for cases and 0.01 +/- 1.14 for controls, p < 0.0001). The difference was in the same direction but was not statistically significant for mean femoral Z-scores (-0.58 +/- 1.15 for cases and -0.22 +/- 1.33 for controls, p < 0.073). These findings confirm the hypothesis of a familial predisposition to low BMD.

How hip and whole-body bone mineral density predict hip fracture in elderly women: the EPIDOS Prospective Study

We conducted a population-based cohort study in 7598 white healthy women, aged 75 years and over, recruited from the voting lists. We measured at baseline bone mineral density (BMD g/cm2) of the proximal femur (neck, trochanter and Ward's triangle) and the whole body, as well as fat and lean body mass, by dual-energy X-ray absorptiometry (DXA). One hundred and fifty-four women underwent a hip fracture during an average 2 years follow-up. Each standard deviation decrease in BMD increased the risk of hip fracture adjusted for age, weight and centre by 1.9 (95% CL 1.5, 2.3) for the femoral neck, 2.6 times (2.0, 3.3) for the trochanter, 1.8 times (1.4, 2.2) for Ward's triangle, 1.6 times (1.2, 2.0) for the whole body, and 1.3 times (1.0, 1.5) for the fat mass. The areas under the receiver operating characteristic (ROC) curves were not significantly different between trochanter and femoral neck BMD, whereas ROC curves of femoral neck and trochanter BMD were significantly better than those for Ward's triangle and whole-body BMD. Women who sustained an intertrochanteric fracture were older (84 +/- 4.5 years) than women who had a cervical fracture (81 +/- 4.5 years) and trochanter BMD seemed to be a stronger predictor of intertrochanteric ([RR = 4.5 (3.1, 6.5)] than cervical fractures ([RR = 1.8 (1.5, 2.3]). In very elderly women aged 80 years and more, hip BMD was still a significant predictor of hip fracture but the relative risk was significantly lower than in women younger than 80 years. In the 48% of women who had a femoral neck BMD T-score less than -2.5, the relative risk of hip fracture was increased by 3, and the unadjusted incidence of hip fracture was 16.4 per 1000 woman-years compared with 1.1 in the population with a femoral neck BMD T-score > or = -1.

[MELAS syndrome with pure vascular manifestation?]

Two stroke-like episodes then a grand mal seizure occurred within nine years in a 42-year-old patient. Neuroradiological findings (CT-scan and MRI) led to the diagnosis of incomplete MELAS syndrome. MRI with T2-weighted images (TR: 1000ms; TE: 35ms) showed two small asignal lesions possibly resulting from hemosiderine. Metabolic studies are required to help decide on muscular biopsies. Histological findings are needed for diagnosis of this form of mitochondrial cytopathy with only stroke-like manifestations.

[Vertebral bone loss in perimenopause. Results of a 7-year longitudinal study]

OBJECTIVES

Rapid bone loss after menopause is generally recognized although the exact chronology of the events, particularly in relation to onset of amenorrhea, remains poorly understood. We assessed bone loss in perimenopausal women over a 7-year period.

METHODS

Twenty-one women with an uneventful past history were enrolled before menopause and followed until menopause had been completely established. Vertebral bone density was measured by biphotonic absorptiometry annually over two 2-year periods. Individual variations in bone density were calculated according to onset of menopause.

RESULTS

Bone loss in the vertebral body increased during the two years preceding menopause (-1.6 +/- 1.5% per year), reached a peak during the first three post-menopausal years (-2.4 +/- 1.6% per year), and then fell off (-1.2 +/- 1.4% per year).

CONCLUSION

Bone loss was independent of calcium intake and appeared to be related mainly to characteristic hormone changes during the perimenopausal period. These findings raise the question as to the need and means of prevention.

Variability of vertebral and femoral postmenopausal bone loss: a longitudinal study

The rate of postmenopausal bone loss varies considerably between individuals and it has been suggested that about 1 in 3 women loses significant amount of bone mineral in the forearm. The rate of vertebral and femoral bone loss was determined by dual-energy X-ray absorptiometry throughout two consecutive 22-month periods, in 93 healthy women who had passed a natural menopause 6-60 months earlier. In all cases the bone changes were normally distributed, ranging from -6.9% to +2.8% per year in the spine and from -7% to +4.8% per year in the femur. No significant relationship was found between the two fractional rates of bone loss. When the women were stratified into three groups according to their individual rate of bone loss, we found that only 20%-47% retained their first classification during the second period of follow-up. In particular, less than 10% of the women showed a rapid rate of bone loss throughout the study. We conclude that spontaneous vertebral and femoral bone loss exhibit a great variability within the first postmenopausal years and that only a small minority of women sustain a fast rate of bone loss over several years. These results raise the question as to whether the evaluation of individual rates of bone loss at menopause might be useful in the identification of women at higher risk of osteoporosis.

Effect of menopause on femoral and vertebral bone loss

The aim of this study was to investigate the effect of menopause on bone loss in the proximal femur and the lumbar spine. The rates of change in bone mineral density (BMD) were measured longitudinally by dual X-ray absorptiometry (DXA) at the femoral neck (FN), Ward's triangle (WT), and trochanter (TR) together with the lumbar spine in 81 healthy postmenopausal women (45-65 years of age) who had passed a natural menopause, 6 months to 12 years before. A significant correlation between the rate of change and interval since menopause was evidenced. The best fit of the data was a binomial function of interval since menopause at the spine, FN, and WT and a simple linear regression at TR level. At each skeletal site, the rate of bone loss (mean +/- SD) was significantly different (p<0.05) and twice as high in women who were between 6 months and 2 years postmenopausal at enrollment (FN, -1.82 +/- 1.1%; WT, -2.43 +/- 1.7%; TR, -1.12 +/- 1.7%) than in those who were beyond 5 years of menopause (FN, -0.48 +/- 0.8%; WT, -0.68 +/- 2.1% TR, 0.41 +/- 1.2%). A poor correlation (r = 0.39 - 0.42, p<0.001) was found between the rate of vertebral and that of femoral postmenopausal bone loss. This study demonstrates that menopause is associated with a rapid and transient bone loss in BMD of the proximal femur, which declines with time after 3 years. These data suggest that therapy should be initiated as early as possible after menopause to prevent bone loss.

[Hormone replacement therapy and early and late prevention of postmenopausal osteoporosis]

Osteoporosis is one of the main features of the ageing process and the cost of health care for osteoporosis-related fractures and their complications is a major incentive for prevention, particularly in developed countries with a continuously ageing population. The earliest strategies for prevention in menopaused women were based on the anti-osteoclastic effect of hormone replacement therapy. Several epidemiological studies have provided proof of its efficacy showing that in treated populations, there is a significant reduction in osteoporosis-related fractures of about 50%, whatever the site of fracture. Although the effects of hormone replacement therapy in the prevention of post-menopausal osteoporosis have been well established, three problems remain. First, what is the degree of efficacy if replacement therapy is started late? Second, what is the effect in patients who have already suffered an osteoporotic fracture? Third, and most importantly, what is the optimal duration of treatment for effective prevention in a given population particularly at risk of hip fracture? These questions suggest new strategies for preventive hormone replacement are needed.