Determinants of change in bone mineral density and fracture risk during bisphosphonate holiday.

UNLABELLED: In a retrospective analysis of 208 osteoporotic patients followed during a bisphosphonate holiday, lower body weight and risedronate use were associated with a more rapid decline in bone mineral density during the bisphosphonate holiday, while bone mineral density (BMD) trends were similar in patients who sustained vs. did not sustain a fracture. INTRODUCTION: A drug holiday has been suggested for some bisphosphonate-treated patients with osteoporosis to minimize potential side effects from prolonged use. However, there is limited information on the evolution of BMD during a bisphosphonate holiday. Our study analyzed the longitudinal course of BMD following bisphosphonate discontinuation and assessed its determinants. METHODS: Retrospective single-center cohort study of osteoporosis patients treated with alendronate or risedronate for at least 2 years and then discontinued their bisphosphonate for a drug holiday. Patients were stratified by bisphosphonate type and by fracture occurrence during drug holiday. RESULTS: A total of 208 patients were included in this analysis (87.5 % female). At the time of bisphosphonate cessation, mean ± SD age was 66.9 ± 8.9 years and BMI 24.5 ± 4.4 kg/m(2). Duration of bisphosphonate treatment was 5.2 ± 2.3 years, and follow-up during holiday was 3.3 ± 1.7 years. During the first 2 years of the holiday, BMD remained stable at the lumbar spine and femoral neck, but declined significantly at the total hip. BMD declined significantly at all sites thereafter. Significant predictors of BMD decline during bisphosphonate holiday included lower BMI at the start of the holiday and change in body weight during the holiday. BMD decline was more pronounced in former risedronate compared to former alendronate users. BMD trends were similar in patients who sustained vs. did not sustain a fracture during the holiday. CONCLUSIONS: BMD at the total hip declines significantly within 1 year of bisphosphonate discontinuation, particularly in lean patients. Additional studies are needed to identify predictors of fracture incidence during a bisphosphonate holiday.

A model system for assessing physicochemical factors affecting calcium absorbability from the intestinal tract.

An in vitro model system was utilized to critically examine physicochemical factors that could play a role in determining the amount of potentially absorbable ionic calcium as well as soluble complexes in the proximal jejunum following ingestion of tricalcium dicitrate, calcium carbonate, or tricalcium diphosphate. The solubility of calcium salts (500 mg calcium each) was tested in 300 ml water containing varying amounts of hydrochloric acid (0, 0.72, 2.4, 7.26, and 24.2 mEq) intended to mimic achlorhydric to peak acid secretory states. Whereas 20% of calcium citrate dissolved in the absence of hydrochloric acid, a negligible amount of calcium carbonate and calcium phosphate underwent dissolution. In solutions containing 0.72-7.26 mEq hydrochloric acid, calcium citrate was more than twofold soluble than calcium carbonate, and calcium phosphate had intermediate solubility. At simulated peak acid secretion, all three salts were completely soluble, or nearly so. To simulate pancreatic bicarbonate secretion, the filtrates obtained from solubility studies were titrated to pH 5, 6, and 7 with sodium hydroxide. Reprecipitation of calcium citrate and calcium carbonate did not occur. However, substantial calcium phosphate reprecipitation took place especially at high pH and in filtrates derived from high hydrochloric acid content. In filtrates derived from reprecipitation experiments (at pH 6 and 7), anionic complexation of calcium was calculated in order to estimate the amount of ionic and complexed calcium. Considerable amount of calcium from dissolved calcium citrate was complexed (60-65%), principally as soluble CaCit-, whereas calcium complexation was negligible in the calcium carbonate and calcium phosphate systems.

Fluoride bioavailability from slow-release sodium fluoride given with calcium citrate.

Clinical pharmacology of slow-release sodium fluoride given with calcium citrate was examined in acute and long-term studies. Following a single oral administration of 50 mg slow-release sodium fluoride, a peak serum fluoride concentration (Cmax) of 184 ng/ml was reached in 2 h; thereafter, serum fluoride concentration declined with a T1/2 of 5.9 h. The concurrent administration of calcium citrate (400 mg calcium) gave an equivalent Tmax (time required to attain Cmax) and T1/2, but a lower Cmax of 135 ng/ml. The coadministration of a meal with fluoride also reduced Cmax but increased Tmax. The area under the serum concentration curve of slow-release sodium fluoride was reduced 17-27% by a meal or calcium citrate. Thus, calcium citrate reduced fluoride absorption and peak fluoride concentration in serum of slow-release sodium fluoride but did not affect the time required to reach peak concentration or the rate of subsequent decline. The effect of a meal was similar, except for a longer period required to reach peak serum concentration. During long-term administration of 25 mg slow-release sodium fluoride coadministered with 400 mg calcium as calcium citrate on a twice daily schedule, the trough level of serum fluoride could be kept between 95 and 190 ng/ml, believed to be the therapeutic window.

Quantitation of incident spinal fractures: comparison of visual detection with quantitative morphometry.

The value of quantitative morphometry in detection of new spinal fractures was assessed in serial radiographs from 83 patients with osteoporosis. From vertebral landmarks on lateral spine radiographs, a computer program allowed calculation of vertebral heights and area. By comparing vertebral dimensions in the two sets of films, incident spinal fractures could be quantitated based either on the minimum criteria of 15% reduction in vertebral height (CM2) or a fall in height and area of 20% and 10% (CM1). The results of quantitative morphometry were compared with those of the consensus and individual readings of visual detection by three experienced investigators in the same paired sets of spinal films. For incident new fractures, the visual consensus method (V-C) showed a very good agreement with individual visual detection (kappa of 0.794 to 0.916) as well as with CM1 (kappa of 0.821). However, there was a poor agreement between the results of consensus reading and of detection by CM2 (kappa of 0.341), due to excessive number of fractures identified by CM2, but not by the visual method. For incident recurrent fractures, there was a poor agreement between V-C and individual visual detection, and between V-C and quantitative morphometry (kappa of 0.306 to 0.496). It was due to severe compression fractures at baseline, which caused further changes in vertebral dimensions difficult to measure accurately by either visual or quantitative morphometry. Thus, if the visual detection of fractures by a consensus of experienced investigators is considered as the "gold standard," quantitative morphometry, based on minimum reduction in vertebral height of 20% accompanied by a minimum decline in area of 10%, provides an objective detection of incident new spinal fractures but not of recurrent fractures.

The effect of varying molar ratios of potassium-magnesium citrate on thiazide-induced hypokalemia and magnesium loss.

This study was conducted to compare the value of an older formulation of potassium-magnesium citrate (K4MgCit2) with newer formulations (K3MgHCit2 and K5MgCit2Cl) with respect to the correction of thiazide-induced hypokalemia and magnesium loss, alkalinizing effect, and citraturic action. Sixty-two healthy volunteers first took hydrochlorothiazide 50 mg/day. After 3 weeks of thiazide treatment (or earlier if hypokalemia developed), they were randomized to take one of three drugs for 3 weeks while continuing thiazide: K4MgCit2 (49 mEq K, 25 mEq Mg, and 74 mEq citrate/day), K3MgHCit2 (49 mEq K, 33 mEq Mg, and 98 mEq citrate/day), and K5MgCit2Cl (49 mEq K, 20 mEq Mg, 10 mEq Cl and 59 mEq citrate/day). Outcome measures were changes in serum potassium and magnesium, and urinary potassium, magnesium, pH, and citrate. The three drugs were equally effective in correcting thiazide-induced hypokalemia. K3MgHCit2 and K4MgCit2 produced a small but significant increase in serum magnesium concentration, whereas K5MgCit2Cl did not. Although all three supplements significantly increased urinary pH and citrate, these effects were more marked with K3MgHCit2 and K4MgCit2 than with K5MgCit2. All three supplements were generally well tolerated, with the lowest side effect profile obtained with K4MgCit2. The new formulation of K3MgHCit2 exerts similar correction of thiazide-induced hypokalemia and magnesium loss, and enhancement of urinary pH and citrate, compared with the older K4MgCit2. However, it is less well tolerated. The new formulation of K5MgCit2Cl does not avert magnesium loss, and has less prominent alkalinizing and citraturic effects than the older preparation.

Pharmacokinetic and pharmacodynamic comparison of two calcium supplements in postmenopausal women.

This randomized crossover study compared the single-dose bioavailability and effects on parathyroid function of two commercially formulated calcium supplements containing 500 mg of elemental calcium. Twenty-five postmenopausal women underwent three phases of study wherein they each took a single dose of calcium citrate with a standard breakfast (as Citracal 250 mg + D), calcium carbonate (as Os-Cal 500 mg + D), or placebo at 8 a.m. Blood samples were drawn at baseline and hourly for 4 or 6 hours after each dose. Fasting and postload urine samples were also collected. Compared with calcium carbonate, calcium citrate provided a 46% greater peak-basal variation and 94% higher change in area under the curve for serum calcium and a 41% greater increment in urinary calcium. Moreover, the decrement in serum parathyroid hormone concentration from baseline was greater after calcium citrate. In conclusion, calcium citrate is more bioavailable than calcium carbonate when given with a meal.

The clinical utility of carotid duplex scanning.

We retrospectively compared the results of duplex scanning (DS) with contrast angiography (CAN) in the evaluation of 119 patients whose 238 carotid arteries were evaluated by both methods within a four-week period. The results of all patients were then categorized by two different definitions of severity of stenosis. Category A classified 1-29% stenosis as mild, 30-69% stenosis as moderate, and 70-99% diameter reduction as severe stenosis. Category B defined mild stenosis as 1-19% lumen diameter reduction, moderate as 20-49% stenosis, and severe as 50-99% stenosis. The findings by each classification were compared in 60 patients with hemispheric symptoms and in 59 patients with nonspecific symptoms. CAN was our "gold standard", and exhibited greater sensitivity, specificity, accuracy, and predictive values than DS. Carotid arteries with 70% stenosis were identified by DS with greater specificity, accuracy, and predictive values than were arteries with 50% stenoses. Only the sensitivity was comparable in categorizations A and B (80% and 83%). All parameters of measurement were superior in patients with hemispheric symptoms. DS alone cannot substitute for CAN in selecting patients for carotid endarterectomy because its error rate exceeded acceptable rates of complications for carotid artery surgery. The false positive rate of DS was 4%. DS failed to diagnose 7 of 19 carotid artery occlusions, 9 of 11 ulcerated plaques, 7 of 119 instances of aortic arch disease, and 13 cases of severe intracranial artery stenosis.

Farm size, land ownership, and fertility in rural Egypt.

PIP: The purpose of this paper is to present the findings of a household level analysis of land availability and fertility variation among farm families in rural Egypt. Data were drawn from a survey conducted in 2 predominantly rural governorates in Lower Egypt in 1978, Beheira and Kafr El Sheikh. They were purposely selected in an attempt to obtain areas representing a range of socioeconomic and demographic conditions. The analytical model that underlies the study postulates that fertility variation in rural areas is influenced by family access to land for cultivation purposes and the conditions governing that access, as well as socioeconomic and demographic control variables. Among the 561 households sampled, the mean value for land ownership was .47. The mean value for household income measured in Egyptian pounds was 112.83 with a standard deviation of 84.76 pounds. The females had been employed 9.7% of the years since marriage. On the average, women had completed less than 3 months of formal education--.32 years. Access to land cultivation was significantly related to the other variables. Land ownership increased with farm size. Family income was closely linked to cultivated area. Landless laboring families had the lowest fertility. Wives of landless laborers were on the average younger, slightly better educated, and less likely to have worked for wages since marriage. The results support the hypothesis that the amount of land available to the family for cultivation is positively related to fertility. Land ownership was negatively related to children ever born. Per capita family income also exerted a negative influence on the number of children ever born. This indicates that income levels were such that the positive nutrition-induced income effect on fertility does not seem to prevail. Age at marriage was negatively associated with fertility and was statistically significant. The strongest variable was the woman's age.^ieng

Selection for nonbuoyant morphological mutants of Caulobacter crescentus.

Morphological mutants of Caulobacter crescentus were isolated by selecting for cells that did not possess normal, buoyancy-conferring stalks. The most prevalent phenotype enriched by the selection was structurally deficient stalks (designated "Cds"), observable as crumpled or flattened stalks. The second phenotype ("Abs") was observed as spontaneous shedding of normal-appearing stalks. Third, one mutant ("Ecs") was isolated that sheds not only stalks, but also miniature stalked and nonstalked cells.

The role of calcium in stalk development and in phosphate acquisition in Caulobacter crescentus.

Calcium was found to stimulate stalk development in Caulobacter crescentus and to relieve the inhibition of development long known to be caused by phosphate. This suggested that phosphate inhibition could be attributed to its interaction with Ca2+, thereby depriving the cells of a factor that promoted development. Calcium was also found to promote phosphate acquisition by the cells, observed as acceleration of growth at extremes of phosphate concentration, as promotion of carbon-source utilization rather than storage, and as support for phosphate-dependent resistance to arsenate inhibition of growth. Cytological studies of dividing cells revealed that stalked siblings had greater access to exogenous phosphate for use in growth or for storage as polyphosphate, and that access of non-stalked siblings to phosphate was dependent on the length of the stalk of the dividing cell. It was concluded that the physiologic role of the stalk is enhancement of phosphate acquisition. The stimulatory role of calcium in this process was attributed to its support of stalk development and to its stabilization of internal membrane/cell envelope association within the cell-stalk juncture.

Caulobacter and Asticcacaulis stalk bands as indicators of stalk age.

The prosthecae (stalks) of dimorphic caulobacters of the genera Caulobacter and Asticcacaulis are distinguished among such appendages by the presence of disk-like components known as stalk bands. Whether bands are added to a cell's stalk(s) as a regular event coordinated with the cell's reproductive cycle has not been settled by previous studies. Analysis of the frequency of stalks with i, i + 1, i + 2, etc. bands 'among more than 7,000 stalks of Caulobacter crescentus revealed that in finite (batch) cultures (in which all offspring accumulate), the proportion of stalks with i + 1 hands was regularly 50% of the proportion of stalks with i bands. This implied that the number of bands correlated with the number of reproductive cycles completed by a stalked cell. In chemostat-maintained perpetual cultures, the proportion was greater than 50% because stalked cells, with their shorter reproductive cycle times, contributed a larger proportion of offspring to the steady-state population than did their swarmer siblings. In Asticcacaulis biprosthecum cells, which bear twin prosthecae, the twins on a typical cell possessed the same number of bands. For both genera, stalk bands provide a unique morphological feature that could be employed in an assessment of age distribution and reproductive dynamics within natural populations of these caulobacters.

Novel peptidoglycans in Caulobacter and Asticcacaulis spp.

Peptidoglycan sacculi free of poly-beta-hydroxybutyric acid were prepared from whole cells of four species of Caulobacter and two species of Asticcacaluis and from morphological mutants of Caulobacter crescentus and Caulobacter leidyi. Acid hydrolysates of the sacculi were analyzed quantitatively, and each of the hydrolysates was found to contain significant amounts of only five ninhydrin-reactive compounds: alanine, glutamic acid, alpha , omega-diaminopimelic acid, muramic acid, and glucosamine. Four types of peptidoglycans were distinguishable on the basis of the molar ratios among these five compounds. The respective ratios were as follows: in C. leidyi, 2:1:1:1:0.8; in Asticcacaulis biprosthecum, 1.7:1.6:1.1:0.7; in the cells of the remaining species, 2:1:1:1.2:0.8; and in stalks shed by the abscission mutant 2NY66, 2:1:1:1:1.67. Thus, in addition to some species differences among these caulobacters, it was found that the peptidoglycan sacculus of the stalked C. crescentus cell is chemically differentiated; the cellular peptidoglycan is richer in muramic acid than is the peptidoglycan of typical gram-negative bacteria, and the peptidoglycan of the stalk is correspondingly rich in glucosamine. Empirical formulas for the repeating units of the peptidoglycans have been inferred on the basis of the molar ratios of their amino components.

Constriction and septation during cell division in caulobacters.

Morphogenesis of the division site in caulobacters had been described as constrictive in Caulobacter spp. and septate in Asticcacaulis excentricus. However, subsequent studies of other gram-negative genera had implied that constrictive division was an artefact resulting from inadequate preservation of septa; exploration of alternatives to osmium fixation, particularly with aldehydes, was recommended. In this study, the appearance of sectioned division sites was reinvestigated in caulobacter cells prepared by 20 different procedures varying with respect to fixation agents, media, schedules, and temperatures, to dehydrating agents, and to embedding resins. Three types of division site morphogenesis were observed: constriction in C. bacteroides and C. crescentus, partial septation in C. leidyi, and complete, undivided septation in A. excentricus and A. biprosthecum. The anatomy of the division site depended on the bacterial strain, not on the method of preparation of the cells for sectioning. These studies confirm the earlier observations on osmium-fixed caulobacter cells and lead to the general conclusion that gram-negative bacteria with tapered poles probably divide by constriction, whereas septation results in blunt cell poles. A pattern of spiral, rather than circular, insertion of new envelope subunits at the cell equator is proposed as a basic developmental difference between constrictive and septate fission in gram-negative bacteria. Since caulobacter prosthecae can develop as extensions of tapered poles formed by constriction, whereas subpolar or lateral prosthecae occur in species with blunt poles resulting from septation, the site of formation of a thick septum appears unsuitable as a site of subsequent envelope outgrowth.

Seasonal variations in urinary risk factors among patients with nephrolithiasis.

Twenty-four hour urine specimens from 5,677 stone-forming patients throughout the United States were analyzed for seasonal variations in urinary risk factors for nephrolithiasis. Determinations were performed for urine volume, pH, calcium, oxalate, phosphorus, sodium, magnesium, citrate, sulfate, uric acid, and the relative supersaturation (RS) of calcium oxalate, brushite, monosodium urate, and uric acid. Criteria for significant seasonal variation included a significant difference in monthly means of risk factors, seasonal grouping of the data by the Student-Newman-Keuls multiple range test, consistent year-to-year trends and a physiologically significant range. Minimum urine volume of 1.54 +/- 0.70 SD L/day occurred in October while a maximum urine volume of 1.76 +/- 0.78 SD L/day was observed during February. Minimum urine pH of 5.94 +/- 0.64 SD was observed during July and August while a maximum pH of 6.18 +/- 0.61 SD was observed during February. Daily urinary excretion of sodium was lowest during August, 158 +/- 74 SD mEq/day and highest during February 177 +/- 70 SD mEq/day. The RS of brushite and uric acid were found to display significant pH-dependent seasonal variation with a maximum RS of uric acid 2.26 +/- 1.98 SD in June and a low of 1.48 +/- 1.30 SD in February. Maximum RS of brushite 2.75 +/- 2.58 was observed during February. Minimum RS of brushite 1.93 +/- 1.70 SD was observed in June. Phosphorus excretion displayed seasonal variation about a spring-fall axis with a maximum value 1042 +/- 373 SD mg/day in April and a minimum value of 895 +/- 289 SD mg/day. Urine volume, sodium, and pH were significantly lower during the summer (June, July, August) than in the winter (December, January, February). The RS of uric acid was higher, but that of brushite and monosodium urate was lower in the summer than in the winter. The seasonal changes observed in urine volume, pH, sodium, and the RS of brushite and uric acid are consistent with summertime sweating and increased physical activity. Seasonal variations in phosphorus excretion are probably dietary in origin. The summertime was characterized by an increased propensity for the crystallization of uric acid but not of calcium oxalate or calcium phosphate.

Calculation of titratable acidity from urinary stone risk factors.

Using urine samples and standard solutions, this study demonstrates that the existing procedure for measuring titratable acidity in the urine is not reliable and may result in overestimates of up to 25%. The accuracy is affected by loss of CO2, the presence of uric acid crystals, and the precipitation of calciumphosphate phases during the titration. A method is presented for calculating titratable acidity, using a number of routinely-measured urine components and a computer program for calculating complex equilibria in the urine. The calculated titratable acidity is shown to be more reliable then the measured one. The results are compiled in a nomogram from which the titratable acidity can be directly read. When the parameters of urine pH, PO4 content and pCO2 are used, the accuracy of the nomogram is > 96% for urine samples with a pH value above 6.0 and > 89% for urine samples with a pH value below 6.0. For all samples, the accuracy is improved to > 97% when the nomogram using uric acid and citrate content is used in additionally.

Principles of management of shotgun wounds.

As an instrument of close range combat, the shotgun has no parallel. At short distances, its destructive capacity parallels that seen from high velocity missile injury. In this study, the history of the shotgun, wound ballistics, principles of initial therapy and special management problems related to shotgun wounds of specific sites are reviewed. An analysis of pooled data on abdominal shotgun wounds is presented. A subset of patients who do not require abdominal exploration exists. Specific problems encountered in defining this subset are enumerated. Three algorithms are presented that summarize our current management approach to shotgun wounds of the torso and extremities.

Management of kinked extracranial cerebral arteries.

Kinked extracranial carotid and vertebral arteries are observed in 10% to 16% of cerebral angiograms. The hemodynamic significance of some kinked carotid arteries has been shown by investigators who documented oculoplethysmographic and angiographic differences accompanying flexion, extension, or rotation changes of the neck and head. In the 3-year period ending November 1985, we performed operations on seven patients to correct six kinked internal carotid arteries and one kinked vertebral artery at the C-2 level. The final decision regarding optimal operative technique was determined during operation, after observing the relative lengths of dissected arteries, envisioning the results of the procedures selected. We performed five segmental resections and end-to-end anastomoses (one vertebral, two common carotid, and two internal carotid arteries). Transection of the internal carotid artery with reimplantation into the side of the common carotid artery was performed twice. All patients became asymptomatic up to 4 years, irrespective of head and neck positions. There were no complications or deaths in these patients. This experience suggests that arterial kinks may constitute tenable indications for operative treatment in patients with transient cerebral ischemia who lack typical stenotic or ulcerative plaques to account for their symptoms. Kinked arteries can be corrected safely and effectively by appropriate surgical procedures.