Spinal extension exercises prevent natural progression of kyphosis.

UNLABELLED: The angle of kyphosis increases with age with the most rapid increase occurring between 50 and 60 years. The progression of kyphosis was prevented in women ages 50-59 years who performed extension exercises three times a week for one year. INTRODUCTION: The purpose of this study was to (1) measure the progression of the angle of kyphosis with age and (2) determine whether spinal extension exercises prevent progression of hyperkyphosis in women 50-59 years of age. METHOD: Part 1: Cross-sectional study of changes in posture with age, determined by measuring spinal curves in 250 women 30-79 years of age. Part 2: One-year prospective, descriptive analysis of the effect of extension exercises on posture in women 50-59 years of age. Depth of the cervical curve (CD), area under the thoracic curve (TA), and height were measured using a device developed at Kansas University Medical Center. Changes in CD and TA in women compliant with extension exercises were compared to those in non-compliant women. RESULTS: Kyphosis increases with age in healthy women, with the greatest difference observed between women 50 and 59 years of age. The progression of kyphosis was greater in women who did not perform extension exercises compared to those who performed extension exercises three times per week for 1 year. The difference in change in CD and TA between the two groups was highly significant (CD p = .0001, TA p = .0001). CONCLUSIONS: Kyphosis increases with age in healthy women. In this study the greatest difference in the angle of kyphosis was observed between the fifth and sixth decade. Exercises which strengthen the extensor muscles of the spine can delay the progression of hyperkyphosis in the group included in this study, i.e., women 50-59 years of age.

Calcium and phosphorus homeostasis in man. Effect of corticosteroids.

Serum calcium and phosphorus levels, urinary excretion rates of calcium, phosphorus, and cyclic adenosine monophosphate (cAMP), and plasma parathyroid hormone (PTH) concentrations were determined in 11 normal subjects and in nine patients maintained on long-term prednisone therapy for chronic obstructive pulmonary disease. These same determinations were repeated in five of the prednisone-treated patients during the course of a seven-day calcium infusion. Prior to the infusion, the prednisone-treated patients demonstrated significantly elevated serum levels of PTH (P less than .005) and increased rates of urinary phosphate and cAMP excreation (P less than .005) when compared with normal subjects. After initiation of calcium infusion, the previous elevations in all of these determinations decreased to near normal levels. These data suggest that the effects of secondary hyperparathyroidism in patients maintained on long-term prednisone therapy may be overcome when calcium is administered intravenously.

Vitamin D metabolism in man. Effect of corticosteroids.

This study evaluated the effects of acute intravenous calcium supplementation on vitamin D metabolism in nine patients maintained on long-term prednisone therapy for chronic obstructive lung disease. Vitamin D turnover studies, employing 1,2-(3)H,4(14)C vitamin D3, and coincident measurement of serum 25-hydroxycholecalciferol (25-OHCC) concentrations demonstration (P less than .05) and half-time (P less than .05) in the prednisone-treated patients when compared with the mean 25-OHCC concentration and half-time found in these patients prior to calcium infusion. However, there was no significant difference in the amounts of 24,25-(OH)2CC) or 1,25-dihydroxycholecalciferol (1,25-(OH)2CC) appearing after calcium infusion. The results of the study showed that the intravenous administration of calcium to corticosteroid-treated patients accelerated the disappearance of 25-OHCC from the plasma of these patients without parallel increases in the production of 1,25-(OH)2CC or 24-25-(OH)2CC.

Resolution of breast pain and calcification with renal transplantation.

Vascular calcification in chronic renal failure and dialysis patients is well-documented and generally considered to be a consequence of decreased phosphorus excretion, secondary hyperparathyroidism, and increased calcium-phosphorus product. Following renal transplantation or parathyroidectomy, gradual resolution of metastatic calcification in the affected areas occurs. The case presented documents the consequence of secondary hyperparathyroidism with calcification of mammary vessels leading to severe breast pain with resolution of the pain and vessel calcification after renal transplantation.

Contributing diagnoses in osteoporosis. The value of a complete medical evaluation.

Osteoporosis often occurs as a consequence of, or is accelerated by, many medical diseases, drug exposures, or other conditions. We called these conditions contributing diagnoses. Although technological advances permit the accurate measurement of bone density, identifying osteoporosis without searching for contributing diagnoses may result in remediable diseases being missed or in the initiation of inadvisable therapy. The value of comprehensive medical evaluation in conjunction with appropriate diagnostic studies was demonstrated in an osteoporosis referral center. We studied 300 consecutive persons who presented to an osteoporosis clinic. Using strict criteria, 180 patients (60%) had osteoporosis. Of these 180 patients, 83 (46%) had one or more contributing diagnosis, ie, a condition thought to accelerate bone loss. The largest single group was composed of persons with past or present exposure to glucocorticoids; the second largest group consisted of women who had undergone premature menopause. In all, 27 different contributing diagnoses were identified. Additionally, in 19 (11%) of the 180 patients with osteoporosis, a contributing diagnosis new to those patients was made. The evaluation of osteoporosis does not only entail measurement of bone density but must also take into consideration a patient's entire medical milieu.

Estrogen and progesterone replacement therapy reduces glucocorticoid-induced bone loss.

This is a retrospective study of 15 postmenopausal or amenorrheic women aged 34-78 years who had taken prednisone for 6-108 months and were followed for 1 year while continuing to take doses of 5-15 mg/day. A total of 8 patients were treated with 0.6256 mg Premarin daily for 25 days and 5 mg/day of medroxyprogesterone on days 15-25 (ERT, group 2); 7 were followed without ERT (group 1). A group of 17 women, matched for age, were randomly selected from our computerized data base to serve as a control group (group 3), and 10 women of similar age who were taking ERT only (group 4) were selected to compare the response to ERT to that of group 2. Bone density (BD) was measured in the lumbar spine baseline and at 1 year using dual-photon or dual-energy x-ray absorptiometry. Spine density did not change significantly during the year of observation in group 1. Although BD decreased in 5 of 7 patients, the change was not significant (-0.034 +/- 0.018 g/cm2, p = 0.10). In group 2 BD increased significantly, with 7 of 8 patients showing an increase (0.037 +/- 0.011 g/cm2, p = 0.008). BD did not change significantly in the control group (0.013 +/- 0.008 g/cm2, p = 0.16). Loss of bone from the spine was significantly greater in group 1 than in controls (p = 0.02), but changes in group 2 were similar to those in the control group (p = 0.66).(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition of mediator release in systemic mastocytosis is associated with reversal of bone changes.

A 59-year-old male presented with systemic mastocytosis with extensive skeletal involvement resulting in vertebral compression fractures and bone pain. Histomorphometric analysis of bone revealed increased mast cells, elevated static parameters of bone resorption, and low bone formation. Serum calcium, phosphorus, and alkaline phosphatase were normal; however, serum 1,25-dihydroxyvitamin D3 and osteocalcin levels were low. Histamine levels in plasma and urine were elevated. Following therapy with ketotifen, the patient had resolution of bone pain along with decreased flushing and pruritus. Elevated plasma and urine histamine levels normalized, as did 1,25-dihydroxyvitamin D3 and osteocalcin levels. Indices of low bone formation improved on therapy. Eroded surfaces improved but remained elevated. This case is the first demonstration that bone symptoms and histomorphometric change in systemic mastocytosis are reversed with inhibition of mast cell degranulation. The role of mast cells and their products in bone metabolism is poorly understood, but the therapy of bone disease in systemic mastocytosis should include inhibition of the release of mast cell products along with the use of histamine antagonist.

Serum osteocalcin is increased in patients with hyperthyroidism and decreased in patients receiving glucocorticoids.

Osteocalcin (OC) is a vitamin K-dependent protein which is synthesized by osteoblasts and is present in the circulation. We measured serum OC concentrations in 10 patients receiving corticosteroids (CS) for chronic obstructive pulmonary disease and in 9 hyperthyroid (HT) patients. Mean values ( +/- SE) were as follows: There was a significant correlation between OC and alkaline phosphatase (r = 0.607; P = 0.006) when CS and HT groups were combined. Elevated serum OC concentrations in hyperthyroid patients may reflect increased osteoblastic activity, while decreased levels in corticosteroid-treated patients may reflect decreased osteoblastic activity.

Long-term anticonvulsant therapy and intestinal calcium absorption.

Twelve patients on anticonvulsant therapy were studied to determine whether or not the drugs induced alterations in gastrointestinal absorption of calcium, response to parathyroid hormone (PTH), or serum 25-hydroxy vitamin D (25-OHD) concentrations. Fractional calcium absorption (FCaA) was determined by giving 45Ca intravenously and orally. The short-term response to PTH was assessed by giving 200 U of parathyroid extract (PTE) intravenously over 15 min and measuring hourly urine cyclic adenosine monophosphate (cAMP) and tubular reabsorption of phosphate (TRP). Calcemic response to PTH was followed by giving intramuscular injections of PTE, 200 U every 6 hr. FCaA was 30.8 +/- 3.7% lower than the normal of 42.2 +/- 2.5% (P less than 0.025), and baseline 25-OHD levels were 30.5 +/- 3.4 ng/ml (normal 15 to 50 ng/ml). Anticonvulsant drugs did not alter renal response to PTE. There was a rise in urinary cAMP from 3.7 +/- 0.23 to 6.1 +/- 0.47 mumol/gm creatinine (P less than 0.005) with a fall in TRP from 87.8 +/- 1.2% to 78.8 +/- 1.6% (P less than 0.005). Serum calcium rose from 9.4 +/- 0.1 to 11.1 +/- 0.3 mg/dl (P less than 0.005). We conclude that FCaA is low in patients receiving anticonvulsant drugs, even when serum 25-OHD levels and the response of bone and kidney to PTH remain normal.

Predicting weight loss success among obese clients in a hospital nutrition clinic.

A retrospective study of 63 obese patients seen in a hospital outpatient nutrition clinic was reported. The majority suffered from one or more other medical problems. The relationship of amount of and rate of weight loss to various factors was examined. The multivariate analysis revealed that either the amount or rate of weight loss was greater in the patients who were more overweight initially, white, male, young, single, older at age of onset of obesity, visited the clinic for a longer period of time but less frequently. Conversely, the amount or rate of weight loss was less in those patients receiving conjugated estrogens, oral contraceptives, propranolol, thioridazine HCl, and those who were receiving behavior modification as treatment.

Osteoporosis associated with mastocytosis confined to bone: report of two cases.

Two women, ages 53 and 46, presented with multiple spontaneous vertebral fractures. Serum calcium, 25OHD, 1,25-(OH)2D, PTH, and 24-h urinary calcium were all normal. Bone mineral analysis (BMA) was performed at the junction of the distal third of the radius by single photon absorptiometry. BMA on Patient 1 was 0.68 g/cm2 and on Patient 2 was 0.58 g/cm2, with the normal being 0.70 g/cm2 and 0.77 g/cm2, respectively. In addition to vertebral fractures, x rays of Patient 2 revealed lytic lesions of the tibia and ulna. Bone biopsies revealed osteopenia associated with generalized eosinophilic fibromastocytosis and increased resorption without evidence of increased numbers of osteoclasts. There was no evidence of extraskeletal mast cell involvement. Our observations contribute to the increasing evidence that mast cells play a direct role in the etiology of osteoporosis in certain patients. Possible pathophysiologic mechanisms include mast cell release of heparin, histamine, prostaglandin D2 or other osteolytic substances.

Scurvy results in decreased collagen synthesis and bone density in the guinea pig animal model.

The effect of severe ascorbic acid deficiency on bone remodeling and collagen synthesis was evaluated in a 21 day experiment, using the scorbutic guinea pig model. Animals (n = 6-7/group) were assigned to one of three groups: scorbutic, pair-fed ascorbic acid-replete, or ad libitum ascorbic acid-replete groups. After 2 weeks, scorbutic animals started voluntarily decreasing food intake and losing weight. By day 19-21, at which time bone and tissue samples were collected and analyzed, scorbutic animals decreased food intake to 46% of usual and lost 9% body weight. Serum 25OHD3, 1,25(OH)2D3, calcium, and albumin were significantly lower (p < 0.05) in the scorbutic animals than in the other groups. Bone mineral density and bone mineral content of the proximal and central femur were significantly lower in the scorbutic group than in the other groups (p < 0.05). Morphometric analysis of tibia indicated significantly lower bone volume, fewer and thinner trabeculae, and a thinner growth plate in the scorbutic group, compared to the pair-fed and ad libitum groups (p < 0.05). Osteoclast surface was about 60% higher in the scorbutic group than in the pair-fed and ad libitum control groups (0.05 < p < 0.10). Mechanical strength of the femur and lumbar vertebral body tended to be lower when bone mass was altered in the same group. Collagen synthesis of articular cartilage and tendons was lower in the scorbutic group than in the pair-fed or ad libitum groups (p < 0.05). In conclusion, scurvy but not food restriction, per se, results in alterations in bone mass and tissue collagen synthesis.

Pyomyositis. Increasing recognition in temperate climates.

Pyomyositis is common in the tropics yet is rarely reported in temperate climates. A woman in whom pyomyositis developed in a temperate climate is presented. Computed tomography was the key in the diagnosis of the disease involving the muscles of the left lateral chest wall. The patient's condition responded to intravenous antibiotics and open abscess drainage. The 31 cases reported in the United States are reviewed. Unfamiliarity still poses a barrier to early diagnosis, although pyomyositis is being more frequently described in temperate climates.

Endocrine studies in a male patient with choriocarcinoma and gynecomastia.

Sex hormone profiles were studied in serum and tumor extracts of a man with pulmonary choriocarcinoma and gynecomastia. Although levels of serum estrogens were elevated as expected, serum androgen levels were uncharacteristically quite high. Tumor extract contained increased quantities of both androgens and estrogens when compared with surrounding normal lung tissue, but lacked the enzymes necessary for androgen biosynthesis while retaining aromatase activity. It is concluded that unlike the usual male patient with choriocarcinoma, the tumor-derived beta-human chorionic gonadotropin stimulated testicular androgen production. These androgens were in turn concentrated by the tumor and converted in part to estrogens. Furthermore, gynecomastia can occur even in the face of high serum androgen concentrations provided total estrogen levels are also disproportionately elevated.

Glucocorticoid-induced osteoporosis.

Glucocorticoids are important in the management of rheumatic diseases. Bone loss is one of the most devastating side effects of glucocorticoids because they inhibit calcium transport, cause secondary hyperparathyroidism, hypogonadism, and impairment of osteoblast function. Efforts to control these side effects minimize bone loss.

Effects of hydrochlorothiazide and dietary sodium restriction on calcium metabolism in corticosteroid treated patients.

The effect of treatment with hydrochlorothiazide (HCT) and dietary sodium restriction on calcium economy in glucocorticoid-treated patients was investigated. Fractional 47Ca intestinal absorption (FCaA) and fractional urinary calcium excretion (FCaEx) were measured in six normal individuals and in ten patients receiving glucocorticoids for chronic obstructive pulmonary disease before and after 60 days of treatment with a 50 mEq sodium diet and HCT 50 mg twice daily. FCaA was significantly decreased on glucocorticoid-treated patients (27.5 +/- 4.3%) when compared to normal individuals (41.8 +/- 2.8%, p less than 0.005). A significant increase in FCaA to 38.9 +/- 4.8%, (P less than .05) was seen in glucocorticoid-treated patients after treatment with HCT and dietary sodium restriction. Baseline FCaEx was higher in glucocorticoid-treated patients than in the normal subjects. A significant decrease in FCaEx after dietary sodium restriction and thiazide administration occurred in both normal (0.99 +/- 0.28% before vs. 0.69 +/- 0.30% after; p less than .025) and glucocorticoid-treated patients (1.46 +/- 0.19% before vs. 0.73 +/- 0.13% after p; less than 0.025). These data suggest that dietary sodium restriction and HCT therapy may improve total body calcium economy in glucocorticoid-treated patients by increasing intestinal calcium absorption and decreasing urinary calcium excretion.

Androblastomas and thyroid disease in postmenopausal sisters.

Androblastomas are virilizing ovarian tumors found predominantly in premenopausal women. Reported are two postmenopausal sisters with androblastomas, the first such occurrence in the literature. An association has been proposed between the familial occurrence of these tumors and thyroid adenomas or nontoxic goiter. Of the two patients studied, one had a history of Graves disease and the other had thyroid cancer. The authors conclude that the associated thyroid pathology in the families described and in the studied patients is inconsistent and does not represent a unique multiple endocrine neoplasia syndrome.

Vertebral compression fractures: how to manage pain, avoid disability.

About 25% of U.S. women over age 50 will suffer one or more vertebral compression fractures related to osteoporosis. Vertebral fractures may be biconcave, anterior wedge, or crush deformities. A fracture is most often precipitated by putting a load on outstretched arms (eg, while raising a window). Back pain is usually incapacitating for a few weeks, then diminishes in severity but remains intense for 2 to 3 months. Acute complications include transient ileus, urinary retention, or (rarely) cord compression. Long-term effects include kyphosis, deconditioning, insomnia, and depression. Initial treatment includes bed rest, pain management with local and systemic analgesia, bracing to improve comfort, and patient reassurance. Long-term management includes spinal stretching exercises, walking, and treatment of underlying osteoporosis with calcitonin or estrogen in selected patients.