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Osteoporosis with vertebral fractures associated with pregnancy and lactation.

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

[Epidemiology of proximal femoral fractures in La Plata, Argentina]. / Epidemiología de las fracturas del fémur proximal en La Plata, Argentina.

The epidemiology of proximal femur fractures (FXf) was studied in the city of La Plata, Argentina. At the time of the study the total population was 288,000 inhabitants and 73,900 (30,700 men and 43,200 women) were 50 years of age and over (Table 1). From May 1, 1989 to April 30, 1990 all the patients admitted in local hospitals with FXf were personally interviewed by one of the authors. Patients living outside the city of La Plata or fractures due to metastatic or Paget disease were excluded. During the period of the study 195 patients with FXf (164 women and 31 men) were registered. The median of age was 80 years in females (range 50 to 96) and 77 years of age (range 50 to 93) in males. The incidence of FXf in women 50 years of age and over was 379.4/100,000 inhabitants and in men 101.0/100,000 inhabitants. The female/male ratio was 3.76 (Table 1). The number of FXf was higher in winter than in summer. (Figure 1). Table 3 indicates the incidence of FXf found in several studies performed in different geographical areas. In females the incidence was similar to that observed in other caucasian populations. The female/male ratio found in the present study is the highest recorded in the literature. This is the first epidemiologic study of osteoporosis performed in Argentina. Further studies should ascertain the low incidence found in males as well as the frequency of osteoporosis in other areas of the country that extend from latitude 22 degrees S to 54 degrees S.

[Bone mineral density of the lumbar spine and proximal femur of normal females in Buenos Aires]. / Densidad mineral de la columna lumbar y femur proximal en mujeres normales de Buenos Aires.

The bone mineral density (BMD) of the lumbar spine and proximal femur was determined in 170 and 131 respectively normal females from 20 to 79 years of age. The BMD was determined by dual photon absorptiometry with a Lunar DP3 equipment. The results per decade of age are shown on table 2. The percentage fall between the 3rd and 8th decades of age at different skeletal sites is summarized on table 3. Meanwhile the bone loss at the lumbar spine and mid-radius from a previous study was approximately 3% before the menopause, the BMD of proximal femur diminished approximately 14% over the neck and 19% at the Ward's triangle during the same period. From age 50 to 80 the average bone loss was similar at the spine and femoral neck (approximately 15%) but it was more severe at the Ward's triangle (approximately 24%). The results obtained in the Buenos Aires females were compared to the values observed in studies performed in United States and Australia using the same equipment. No differences were found among the three populations using the Bonferroni's analysis for multiple comparisons. The BMD appears to be similar in different caucasian populations when the same type of equipment is used, but the values cannot be compared with the results obtained with other equipment. A sustained diminution of the proximal femur BMD was observed from age 20 to 80, whereas over the spine a distinct difference before and after the menopause was found.

[Clinical, humoral and scintigraphic assessment of a bisphosphonate as potential treatment of diaphyseal dysplasia: Ribbing and Cammurati-Engelmann diseases]. / Evaluación clínica, humoral y centellográfica de un bisfosfonato como posible tratamiento en dos casos de displasias diafisarias: las enfermedades de Ribbing y Camurati-Engelmann.

Cammurati-Engelmann's Disease or Progressive Diaphyseal Dysplasia (PDD), is a rare autosomal dominant disorder, sometimes non hereditable, which begins in childhood, and is characterized by symmetrical excess of osseous apposition in diaphysis and metaphysis of long bones. In severe cases skull and vertebrae could be involved. Clinically, patients refer limb pain, muscular weakness and atrophy, easy fatigability and waddling gait. Later on S. Ribbing described an illness that he thought was a separate entity with sclerosis and enlargement of diaphysis of femora and tibiae, which begins after puberty, is less extensive, not always symmetric and without gait or neurological involvement. Some authors think it may be an adult form of the PDD. As no specific treatments are available we report one case of each entity, treated with the bisphosphonate pamidronate, by the oral route. A white female, 69 years old, with clinic and radiology of Ribbing's Disease, had positive scintigraphy in the affected areas and elevated bone biochemical markers: Serum alkaline phosphatase (SAP): 57 UKA. Total urinary hydroxyproline (THP): 60 mg/24 h. Bone Gla protein (BGP): 40 ng/ml. Considering the high bone turnover treatment with oral pamidronate, 400 mg/day plus Calcium 1g/day was started, dose was then progressively reduced. After two months pain almost disappeared, and THP became normal: 14 mg/24 h; with normalization of BGP values: 8 ng/ml, and a decrease of SAP: 21 UKA, 99mTc MDP uptake by affected bones decreased after 1 year of treatment. Because of these results we decided to begin treatment in a white female 17 years old, 32 kg weight, 1.47 m height with PDD characteristics and also a high bone turnover (THP: 95 mg/24 h. SAP: 32 UKA). After six months of Calcium 1 g/day, given with meals, and oral pamidronate 100 mg/day, she became painless with normal strength and gait, almost normalization of THP (48 mg/24 h). Although a small decrease of SAP, and no charges in scintigraphy. These results obtained with pamidronate suggest that it may be useful to treat dysplasias with high bone turnover.

Osteoinmunología: Una visión integrada de los sistemas inmunológico y óseo. Nuevas perspectivas de las enfermedades óseas / Osteoimmunology: An Integrated Vision of Immune and Bone Systems. Novel Perspectives for Bone Disease

Esta 3ª parte se propone comentar los mecanismos inmunológicos involucrados en el deterioro de la masa ósea en algunas enfermedades autoinmunes. Dado que estas son numerosas (múltiples componentes del Síndrome Poliglandular Autoinmune, Enfermedad celíaca, Síndrome de Crohn, colitis ulcerosa, HIV, patologías reumatológicas, anemia perniciosa, asma bronquial e incluso periodontitis), se eligieron cuatro afecciones que actualmente podrían tener un mayor interés: La Artritis Reumatoidea por ser la patología paradigmática del deterioro óseo; la posmenopausia, donde se describe poco el rol autoinmune; el HIV, por la prolongada sobrevida actual con mayores posibilidades de lesiones óseas y la Periodontitis, como una incursión en el compromiso odontológico, a veces poco conocido por el médico. En muchos casos el conocimiento de estos mecanismos ha contribuido a la generación de medicamentos específicos logrando éxitos terapéuticos con mejor calidad de vida. Rev Argent Endocrinol Metab 51:197-204, 2014 Los autores declaran no poseer conflictos de interés.

The objective of this communication is to review the immune mechanisms involved in the pathogenesis of bone damage in some autoimmune diseases. As they are numerous (autoimmune polyendocrinopathy , celiac disease, Crohn's disease, ulcerative colitis, HIV, rheumatic diseases, bronchial asthma, pernicious anemia, periodontitis, etc.), we selected only four: Rheumatoid Arthritis, because of its typical bone lesions; post­menopause, because the immune components are not so often described; HIV, because of the current longer survival time with higher possibilities of bone lesions, and Periodontitis, in order to have an overview of dental aspects of this pathology. In many cases, knowledge of these mechanisms has contributed to the de­velopment of specific drugs that have led to therapeutic success and an improved quality of life. Rev Argent Endocrinol Metab 51:197-204, 2014 No finantial conflicts of interest exist.

Osteoinmunología: Una visión integrada de los sistemas inmunológico y óseo. Nuevas perspectivas de las enfermedades óseas / Osteoimmunology: An Integrated Vision of Immune and Bone Systems. Novel Perspectives for Bone Diseases

Dado que tanto las células inmunes como las hematopoyéticas se originan en la médula ósea no es sorprendente la interrelación entre ambos sistemas. Si bien las células de linaje osteoblástico son las principales para influenciar la diferenciación y la activación osteoclástica, las células del estroma que originan osteoblastos, las células hematopoyéticas no estromales, los linfocitos, junto con interleukinas y factores de crecimiento, también afectan la función de las células óseas. Rev Argent Endocrinol Metab 51:25-29, 2014 Los autores declaran no poseer conflictos de interés.

As both the immune and hematopoietic cells originate in the bone marrow, it is not surprising that there should be an interaction between these two systems. While osteoblasts have the main capacity to influence differentiation and activation of osteoclasts, osteoblast-producing stromal cells, non-hematopoietic stromal cells, lymphocytes, interleukins and growth factors also affect bone cell function. Rev Argent Endocrinol Metab 51:25-29, 2014 No financial conflicts of interest exist.

Osteoimmunología: Una visión integrada de los sistemas inmunológico y óseo. Nuevas perspectivas de las enfermedades óseas / Osteoimmunology: An Integrated Vision of Immune and Bone Systems. Novel Perspectives for Bone Diseases

La osteoinmunología es un campo de investigación dedicado al estudio de la interacción entre el sistema inmune y el tejido óseo. Numerosas evidencias demuestran que ambos comparten mecanismos regulatorios. Esta interacción se produce por contacto directo entre las células de ambos sistemas y por la acción de mediadores regulatorios inmunes, citoquinas y factores de crecimiento. El objeto de esta revisión es proporcionar una visión global de la interacción entre las células óseas y las células inmunes y el rol que desempeñan en el mutuo desarrollo y función. El mayor conocimiento de la interacción de estos dos sistemas conduce a una mejor interpretación del papel de la inmunología en la patogénesis de la pérdida de la masa ósea.

Osteoimmunology is a research field that deals with the study of the interaction between the immune system and bone tissue. Enough evidence demonstrates that they share regulatory mechanisms. This interaction occurs through direct contact between the cells of both systems and by the action of immune regulatory mediators, cytokines and growth factors. The aim of this review is to provide an overview of the interaction between bone and immune cells and the role they play in the mutual development and function. A greater knowledge of the interaction of these two systems will allow a better understanding of the role of immunology in the pathogenesis of bone mass loss.

Prevención y tratamiento de la osteoporosis en pacientes con Mieloma múltiple, estadios iniciales de Carcinoma de mama y Cáncer de próstata / Prevention and treatment of osteoporosis in multiple myeloma, early stages of breast cancer and prostate cancer

Se ha efectuado una revisión de los trabajos sobre la fisiopatología del MM y sobre el tratamiento de las lesiones osteoporóticas que se presentan en casi todos los casos. Es sabido que los bifosfonatos son sumamente efectivos por lo que se comentan los actuales esquemas de tratamiento tomando en cuenta los recientes consensos. Hay un acuerdo prácticamente unánime en la eficacia del pamidronato y el zoledronato endovenosos aplicados mensualmente durante dos años, siendo aceptado el uso del clodronato oral en Europa pero no en EE.UU. Aunque mejorarían la calidad de la sobrevida, los bifosfonatos no la prolongarían. Se refieren las precauciones que habría que tomar para evitar la osteonecrosis de mandíbula, una complicación de las dosis altas de bifosfonatos que se ha comunicado con mayor frecuencia durante los últimos años. Se destaca la importancia de la consulta odontológica frecuente y del permanente cuidado dental.

The aim of this review is to discuss recent findings in the physiopathology and treatment of osteoporotic lesions present in almost all patients with MM. The efficacy of bisphosphonates is well known, so we summarize the current treatment schedules according to the most recent consensus. Pamidronate and Zoledronate are equally effective and universally accepted. They should be administered intravenously on a monthly basis for two years. Oral clodronate is accepted in Europe but not in USA. Even if bisphosphonates provide a better quality of life, they do not increase survival. Because osteonecrosis of the jaw has been repeatedly reported after high doses of bisphosphonates, we discuss the necessary precautions to prevent this condition emphasizing frequent dental care and examinations.

Impacto óseo en el tratamiento del cáncer de mama: PARTE II / Bone impact in breast cancer treatment

El cáncer de mama es uno de los tumores más frecuentes en la mujer. Más del 70 % de estas pacientes presenta en la lesión marcación positiva para receptor de estrógeno, receptor de progesterona o ambos En la última década la mortalidad por cáncer de mama ha disminuido entre 6-8 %. Ésto podría deberse a la detección temprana de la lesión, al tratamiento coadyuvante con quimioterapia y tratamiento hormonal, ya sea con bloqueo de estrógenos o ablación ovárica. La depleción de estrógenos establece incremento de la resorción ósea, disminución de la masa ósea y aumento en la tasa de fractura por osteoporosis. La introducción de los inhibidores de la aromatasa ofrece resultados promisorios en el tratamiento del estadio temprano del cáncer de mama. Sin embargo varios estudios clínicos han demostrado que la deprivación de estrógenos inducida por los mismos daña seriamente la salud ósea. Debido a esto, la evaluación sistemática de estas pacientes que incluye la medición de la masa ósea, el estudio del metabolismo mineral y la determinación de factores de riesgo para osteoporosis, sería necesaria para introducir medidas de prevención y/o tratamiento. El uso de bifosfonatos podría ser de utilidad ya que aumenta la masa ósea y reduce la remodelación ósea, aunque no ha sido demostrada su utilidad en reducir la tasa de fractura en este grupo de pacientes.

Breast cancer is one of the most frequent tumors in women. More than 70 % of these patients develop endocrine-responsive disease with estrogen receptor-positive, progesterone receptor-positive tumors or both. In the last decade, breast cancer mortality has decreased by 6-8 %. This could be due to early screening and to adjuvant treatment with chemotherapy as well as hormonal treatment, either with estrogen blockage or ovary ablation. Estrogen depletion implies an increase in bone resorption, bone mass decrease and growth of the osteoporotic fractures The introduction of aromatase inhibitors offers promissory results in the early-stage breast cancer treatment. However, many clinical trials have demonstrated that estrogen deprivation induced by aromatase inhibitors seriously affects bone health. A systematic evaluation of these patients, including bone mass measurement, assessment of mineral metabolism and determination of risk factors for osteoporosis would be necessary to introduce prevention and/or treatment measures. Bisphosphonates may be useful since they increase bone mass and reduce bone remodeling, although their usefulness in reducing the fracture rate has not been demonstrated in this group of patients.

Prevención y tratamiento de la osteoporosis en cáncer de próstata: Recomendaciones / Prevention and treatment of osteoporosis in prostate cancer: Recommendations

La osteoporosis y las fracturas óseas son observadas con frecuencia como una complicación de la terapia de deprivación androgénica en hombres con cáncer de próstata. Varias terapias utilizadas en el tratamiento del cáncer de próstata, en particular la terapia de privación de andrógenos para el cáncer de próstata, están asociadas con una significativa pérdida de la masa ósea y con aumento en el riesgo de fractura. El uso de bifosfonatos parece atenuar la pérdida ósea, aunque el impacto a largo plazo sigue siendo incierto debido al insuficiente seguimiento. Varios agentes, tales como denosumab y toremifene, han mostrado ser prometedores en la reducción del riesgo de fractura en estos pacientes. El tratamiento adyuvante endocrino con deprivación androgénica puede considerarse un factor de riesgo para el desarrollo de osteopenia, osteoporosis y fractura ósea, pudiendo ser mitigada por el tratamiento apropiado de bifosfonatos. La identificación de factores de riesgo para osteoporosis en cada paciente podría colaborar en la toma de decisión acerca del inicio del tratamiento con bifosfonatos en pacientes con la terapia de deprivación androgénica. Los pacientes deben ser instruidos sobre aquellos factores relacionados con este riesgo. Modificaciones en estilo de vida podrían beneficiar su salud general y ósea.

Osteoporosis and bone fractures are frequently overlooked complications of androgen deprivation therapy in men with non-metastatic prostate cancer. Several therapies commonly used in the treatment of prostate cancers, particularly in androgen deprivation therapy for prostate cancer, are associated with significant bone loss and with an increase in fracture risk. The use of bisphosphonates seems to attenuate bone loss, although the long-term impact remains unclear because of insufficient follow-up. Several agents, such as denosumab and toremifene, have shown to be promising in reducing fracture risk in these patients. Adjuvant endocrine therapy with androgen deprivation can be considered a risk factor for the development of osteopenia, osteoporosis, and bone fracture, which can be mitigated by appropriate bisphosphonate therapy. Clear identification of risk factors for osteoporosis in individual patients could help in decision-making about whether to initiate treatment with bisphosphonates in patients under androgen deprivation therapy. Patients need to be educated about this risk and other measures to avoid this complication, including lifestyle modifications that may benefit their general and bone health.

Friendship, proximity, and self-disclosure.

Patterns of self-disclosure were explored by means of a questionnaire administered to pairs of roommates and hallmates (non-roommates living on the same floor) in freshman dormitories. It was predicted and found that friendship was more highly related to self-disclosure in intimate than in non-intimate topic areas, whereas proximity was more highly related to disclosure in non-intimate than in intimate areas. It was also found that friendship and intimate disclosure were more highly related among women than among men. These findings emphasize the interplay of personal, role-related, and environmental factors which underlie patterns of friendship and self-disclosure. They also point to the importance of viewing self-disclosure in differentiated terms, rather than as single monolithic entity. Other findings of both substantive and methodological interest are reported. For example, there was a strong tendency for respondents to overemphasize the degree to which their patterns of giving and receiving personal information were symmetrical. There was also a tendency for respondents to report giving more disclosure than they received in non-intimate areas, but not in intimate areas.

Epidemiology of hip fractures in an urban population of central Argentina.

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