Association of Severity of Coronary Lesions with Bone Mineral Density in Postmenopausal Women.

BACKGROUND: Coronary artery disease (CAD) and osteoporosis (OP) are common diseases in postmenopausal women. In both cross-sectional and longitudinal epidemiologic studies, low bone mass has been related to increased frequency of CAD. However, available data on the relationship between bone mineral density (BMD) and severity of coronary lesions is limited. OBJECTIVE: To investigate association between the BMD and severity of coronary lesions assessed by Gensini score in postmenopausal women. METHODS: This study included 122 postmenopausal women who were diagnosed with CAD. These patients were divided into two groups according to the severity of coronary lesions assessed by the Gensini score - patients with mild coronary lesions (Gensini score < 25) and patients with severe coronary lesions (Gensini score ≥ 25). Femoral neck mineral density was measured with dual energy X-ray absorptiometry (DXA). RESULTS: The study included postmenopausal women aged 64.31 ± 4.71 years, 85 of whom (69.7%) exhibited severe coronary lesions. Participants with severe coronary lesions had a significantly higher T score than did those with mild coronary lesions at the femoral neck (p < 0.05). The mean T-score was -0.84 ± 1.01 in mild coronary lesions group, -1.42 ± 1.39 in severe coronary lesions group (p < 0.05). Multivariable logistic regression analysis showed that osteopenia-osteoporosis at the Femoral neck (odds ratio 2.73; 95% confidence interval 1.06 to 6.13) was associated with an increased risk of developing severe coronary lesions. The multiple regression model showed that T-scores (b = -0.407, SE = 0.151, p=0.007) were the independent predictors of Gensini score. CONCLUSION: The relationship between severity of coronary lesions and BMD was significant in postmenopausal women. BMD, a low-cost technique involving minimal radiation exposure, widely used for osteoporosis screening, is a promising marker of severity of coronary lesions.

Association of Severity of Coronary Lesions with Bone Mineral Density in Postmenopausal Women / Associação entre Gravidade das Lesões Coronarianas e Densidade Mineral Óssea em Mulheres Pós-Menopausa

Abstract Background: Coronary artery disease (CAD) and osteoporosis (OP) are common diseases in postmenopausal women. In both cross-sectional and longitudinal epidemiologic studies, low bone mass has been related to increased frequency of CAD. However, available data on the relationship between bone mineral density (BMD) and severity of coronary lesions is limited. Objective: To investigate association between the BMD and severity of coronary lesions assessed by Gensini score in postmenopausal women. Methods: This study included 122 postmenopausal women who were diagnosed with CAD. These patients were divided into two groups according to the severity of coronary lesions assessed by the Gensini score - patients with mild coronary lesions (Gensini score < 25) and patients with severe coronary lesions (Gensini score ≥ 25). Femoral neck mineral density was measured with dual energy X-ray absorptiometry (DXA). Results: The study included postmenopausal women aged 64.31 ± 4.71 years, 85 of whom (69.7%) exhibited severe coronary lesions. Participants with severe coronary lesions had a significantly higher T score than did those with mild coronary lesions at the femoral neck (p < 0.05). The mean T-score was −0.84 ± 1.01 in mild coronary lesions group, −1.42 ± 1.39 in severe coronary lesions group (p < 0.05). Multivariable logistic regression analysis showed that osteopenia-osteoporosis at the Femoral neck (odds ratio 2.73; 95% confidence interval 1.06 to 6.13) was associated with an increased risk of developing severe coronary lesions. The multiple regression model showed that T-scores (b = −0.407, SE = 0.151, p=0.007) were the independent predictors of Gensini score. Conclusion: The relationship between severity of coronary lesions and BMD was significant in postmenopausal women. BMD, a low-cost technique involving minimal radiation exposure, widely used for osteoporosis screening, is a promising marker of severity of coronary lesions.

Resumo Fundamento: A doença arterial coronariana (DAC) e a osteoporose são doenças comuns em mulheres pós-menopausa. Tanto em estudos transversais como em estudos epidemiológicos longitudinais, a massa óssea diminuída foi relacionada à frequência aumentada de DAC. No entanto, dados disponíveis sobre a relação entre densidade mineral óssea (DMO) e gravidade das lesões coronarianas são limitados. Objetivo: Investigar a associação entre DMO e gravidade das lesões coronarianas avaliadas pelo escore de Gensini em mulheres pós-menopausa. Métodos: Este estudo incluiu 122 mulheres pós-menopausa diagnosticadas com DAC. As pacientes foram divididas em dois grupos de acordo com a gravidade das lesões coronarianas avaliada pelo escore de Gensini - pacientes com lesões coronarianas leves (escore de Gensini < 25) e pacientes com lesões coronarianas graves (escore de Gensini ≥ 25). A densidade mineral do colo femoral foi medida por absorção de raios-X de dupla energia (DXA). Resultados: O estudo incluiu mulheres pós-menopausa com idade de 64,31 ± 4,71 anos, 85 delas (69,7%) com lesões coronarianas graves. Pacientes com lesões coronarianas graves apresentaram um escore T mais elevado que aquelas com lesões coronarianas leves no colo femoral (p < 0,05). O escore T médio foi -0,84 ± 1,01 no grupo com lesões leves, e -1,42 ± 1,39 no grupo com lesões graves (p < 0,05). A análise de regressão logística multivariada mostrou que a osteopenia-osteoporose no colo femoral (odds ratio 2,73; intervalo de confiança de 95% 1,06 - 6,13) esteve associada com um risco aumentado de se desenvolver lesões coronarianas graves. O modelo de regressão múltipla mostrou que os escores T (b = -0,407; EP= 0,151; p = 0,007) foram preditores independentes do escore de Gensini. Conclusão: Encontrou-se uma relação significativa entre a gravidade das lesões coronarianas e a DMO em mulheres pós-menopausa. DMO, uma técnica de baixo custo que envolve mínima exposição à radiação, e amplamente utilizada no rastreamento de osteoporose, é um marcador promissor da gravidade de lesões coronarianas graves.

Enfermedad de Camurati-Engelmann / Camurati-Engelmann disease

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First Korean Case of Infantile Hypophosphatasia with Novel Mutation in ALPL and Literature Review.

Hypophosphatasia is a rare hereditary disorder characterized by defective bone and tooth mineralization and deficiency of tissue non-specific alkaline phosphatase activity. The prognosis for the infantile form is poor, with approximately 50% of patients dying within the first year of life from respiratory failure. We describe the clinical and biochemical findings as well as the molecular analysis of a Korean boy with infantile hypophosphatasia and present a literature review. A 1-month-old boy visited the clinic because of poor feeding, frequent vomiting, hypotonia, and failure to thrive from birth. Laboratory tests revealed high total calcium, low phosphorous, low alkaline phosphatase, low parathyroid hormone, and normal 25-hydroxyvitamin D. Intravenous hydration with normal saline was started, and dietary calcium intake was restricted. Skeletal X-rays showed a markedly increased distance of the anterior fontanelle, impaired mineralization, and rachitic changes in the metaphyses. By Sanger sequencing of the ALPL gene, we identified two heterozygous variants, including a missense (c.334G>A; p.Gly112Ser) and a nonsense (c.1039C>T; p.Gln347*) variant. The c.334G>A (p.Gly112Ser) variant had previously been reported in a patient with lethal type hypophosphatasia, while the nonsense c.1039C>T (p.Gln347*) variant was novel. In the current case, the accurate diagnosis and prompt intervention-including dietary calcium intake restriction, tracheostomy to prevent progression to respiratory failure, and fundoplication with gastrostomy to ensure the administration of adequate calories-seemed to play an important role for avoiding preventable morbidity and premature mortality.

Accelerated bone turnover identifies hemiplegic patients at higher risk of demineralization.

Immobilization osteoporosis represents a severe complication in hemiplegic patients (HPs), causing fragility fractures, which may occur during rehabilitation reducing functional recovery and survival. The aim of the study was to investigate determinants of bone loss, independent from length of immobilization, which may be useful in early identification of HPs at higher risk of demineralization. Forty-eight HPs of both sexes underwent anthropometric measurements, evaluation of scores of spasticity and of lower limb motory capacity. Laboratory tests were performed. On serum: calcium; phosphorus; creatinine; ALP; iPTH; 25(OH) vitamin-D; sex hormones; Δ4-androstenedione; DHEA-S; insulin; IGF-1; FT3; FT4; TSH; c-AMP. On urine: c-AMP and calcium/creatinine ratio. Two bone turnover markers were measured: serum osteocalcin (BGP) and urinary deoxypyridinoline (DPD). Bone mineral density was determined at both femoral necks, defining a percentage difference in bone loss between paretic and non-paretic limb, thus controlling for the complex cofactors involved. Only bone turnover markers significantly and directly correlated with the entity of demineralization, controlling for age, sex and length of immobilization in the multivariate analysis (BGP coefficient estimate=0.008; SE=0.003; p=0.020; DPD coefficient estimate=0.005; SE=0.002; p=0.036). BGP and DPD are not dependent on anthropometric and endocrine-metabolic parameters, disability patterns and duration of immobilization, thus represent independent determinants of the degree of demineralization. A cutoff was defined for BGP and DPD above which subjects show significantly greater risk of demineralization. The immobilization event generates more severe bone loss when it occurs in subjects with higher bone turnover. BGP and DPD measurements may be of primary importance for early identification of HPs at risk, with relevant preventive implications.

Trastorno mineral y óseo asociado a la enfermedad de Cacchi-Ricci / Mineral and bone disorder associated with Cacchi-Ricci disease

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The relationship between intact PTH and biointact PTH (1-84) with bone and mineral metabolism in pre-dialysis chronic kidney disease (CKD).

OBJECTIVES: Abnormalities in PTH are implicated in the pathogenesis of bone abnormalities in chronic kidney disease (CKD)-mineral bone disorder (CKD-MBD). PTH concentrations are important in clinical decision and management. This emphasises the importance of providing an assay which measures biologically active PTH. We compared concentrations of intact PTH with biointact PTH (1-84) in CKD and end stage renal disease (ESRD) and investigated the relationship between the 2 PTH assays with bone and mineral laboratory parameters and bone mineral density (BMD) in CKD. DESIGN AND METHODS: We assessed 140 patients (61 in ESRD and 79 with CKD stages 1-4) in this cross-sectional study. We measured biointact PTH (1-84) as well as routine biochemical parameters on all subjects. In the CKD cohort, bone turnover markers; bone alkaline phosphatase (BAP) and tartrate resistant acid phosphatase (TRACP)-5b and bone mineral density (BMD) were also determined. RESULTS: In ESRD, intact PTH concentration was significantly higher compared to biointact PTH (1-84) (422 [443] v/s 266 [251] pg/mL, (p<0.001) with an average bias of 60%. In CKD, intact PTH concentration was also higher compared to biointact PTH (1-84) (79[55] v/s 68[49] pg/mL p<0.001) with an average bias of 18%. Only the biointact PTH (1-84) assay showed any significant correlation with serum calcium concentrations (r=-0.26, p<0.05) and phosphate (r=0.25, p<0.05) in CKD. Following multilinear regression analysis and adjustment for all significant co-variables, only eGFR, BAP and 25 (OH)vitamin remained significantly associated with intact PTH and biointact PTH (1-84). The strength of association was stronger between BAP and biointact PTH (1-84) (biointact PTH (1-84): p=0.007, intact PTH: p=0.01). In adjusted analyses, only biointact PTH (1-84) was significantly associated with BMD at the fore-arm (FARM) (p=0.049). CONCLUSIONS: The study confirms the differences between intact PTH and biointact PTH (1-84) in ESRD. Whilst there may be similarities in the diagnostic ability of both intact and biointact PTH (1-84), our data suggest that biointact PTH (1-84) assay may better reflect bone metabolism and BMD in CKD. Further longitudinal studies are needed.

Relación de la litiasis renal cálcica recidivante con riesgo de pérdida de densidad mineral ósea y fracturas / Relation of renal lithiasis relapses at risk of bone density loss and fractures. Study of bone remodeling markers as predictors for risk of fracture

Objetivo: Establecer puntos de corte de los niveles de marcadores de remodelado óseo mediante curvas ROC que nos permita realizar un cribado de pacientes con pérdida de densidad mineral ósea y alto riesgo de fractura osteoporótica. Material y métodos: Estudio transversal con 182 pacientes de Andalucía oriental distribuidos en grupos en función de la actividad de la actividad litogénica. Aparte de las variables clínicas, se realizaron estudios densitométricos (DEXA) y determinaciones de los marcadores bioquímicos de remodelado óseo en sangre periférica a todos los pacientes: β-crosslaps, osteocalcina, β-crosslaps/ostecalcina, calciuria 24 horas y calcio/creatinina en orina de ayunas. Resultados: Se apreciaron diferencias significativas en los valores séricos de fosfatasa alcalina, PTHi, osteocalcina, β-crosslaps y β-crosslaps/osteocalcina que se encuentran más elevados en el grupo de pacientes con actividad litogénica grave, así como una mayor pérdida de densidad ósea. Discusión: A partir de marcadores de remodelado óseo puede estimarse el riesgo de un paciente de presentar actividad litogénica grave con una sensibilidad entre 75-85%. Así, podemos realizar un control clínico y analítico de los pacientes con el fin de detectar la actividad litiásica y evitar la pérdida de densidad mineral ósea que además supone un riesgo sobreañadido de fractura ósea osteoporótica (AU)

Objective: Establish the cut-off point for markers of bone remodeling marker using ROC curves that allow us to have a selection of patients with bone mineral density loss and a high risk of osteoporotic fracture Material and methods: Transversal study with 182 patients from eastern Andalusia (Spain), distributed in groups based on lithogenic activity. In addition to the clinical variables, densitometry studies were carried out (DEXA) and the assessment of biochemical markers for bone remodeling in peripheral blood for all patients: β-crosslaps, osteocalcin, β-crosslaps/osteocalcin, 24-hr calciuria and calcium/creatinine in urine after fasting. Results: Significant differences were seen in serum values for alkaline phosphatase, PTHi, osteocalcin, β-crosslaps y β-crosslaps/osteocalcin were higher in the group of patients with serious lithogenic activity, as well as a greater loss of bone density. Discussion: Based on bone remodeling markers, the risk of a patient having serious lithogenic activity can be estimated with a sensitivity of between 75-85%. Thus, we can perform clinical and analytical controls in patients to detect lithiasis activity and avoid the loss of bone mineral density which is also an added risk of osteoporotic bone fracture (AU)

Risk factors for developing mineral bone disease in phenylketonuric patients.

There is a compromised bone mass in phenylketonuria patients compared with normal population, but the mechanisms responsible are still a matter of investigation. In addition, tetrahydrobiopterin therapy is a new option for a significant proportion of these patients and the prevalence of mineral bone disease (MBD) in these patients is unknown. We conducted a cross-sectional observational study including 43 phenylketonuric patients. Bone densitometry, nutritional assessment, physical activity questionnaire, biochemical parameters, and molecular study were performed in all patients. Patients were stratified by phenotype, age and type of treatment. The MBD prevalence in phenylketonuria was 14%. Osteopenic and osteoporotic (n=6 patients) had an average daily natural protein intake significantly lower than the remaining (n=37) patients with PKU (14.33 ± 8.95 g vs 21.25 ± 20.85 g). Besides, a lower body mass index was found. There were no statistical differences in physical activity level, calcium, phosphorus and fat intake, and in phenylalanine, vitamin D, paratohormone, docosahexaenoic and eicosapentaenoic acid blood levels. Mutational spectrum was found in up to 30 different PAH genotypes and no relationship was established among genotype and development of MBD. None of the twelve phenylketonuric patients treated with tetrahydrobiopterin (27.9%), for an average of 7.1 years, developed MBD. Natural protein intake and blood levels of eicosapentaenoic acid were significantly higher while calcium intake was lower in these patients. This study shows that the decrease in natural protein intake can play an important role in MBD development in phenylketonuric patients. Therapy with tetrahydrobiopterin allows a more relaxed protein diet, which is associated with better bone mass.

Time of progression to osteopenia/osteoporosis in chronically HIV-infected patients: screening DXA scan.

BACKGROUND: Algorithms for bone mineral density (BMD) management in HIV-infected patients are lacking. Our objective was to assess how often a dual-energy x-ray absorptiometry (DXA) scan should be performed by assessing time of progression to osteopenia/osteoporosis. METHODS: All DXA scans performed between 2000 and 2009 from HIV-infected patients with at least two DXA were included. Time to an event (osteopenia and osteoporosis) was assessed using the Kaplan-Meier method. Strata (tertiles) were defined using baseline minimum T scores. Differences between strata in time to an event were compared with the log-rank test. RESULTS: Of 391 patients (1,639 DXAs), 49.6% had osteopenia and 21.7% osteoporosis at their first DXA scan. Of the 112 (28.6%) with normal BMD, 35.7% progressed to osteopenia; median progression time was 6.7 years. These patients were stratified: "low-risk" (baseline minimum T score >-0.2 SD), "middle-risk" (between -0.2 and -0.6 SD), and "high-risk" (from -0.6 to -1 SD); median progression time to osteopenia was 8.7, >7.2, and 1.7 years, respectively (p<0.0001). Of patients with osteopenia, 23.7% progressed to osteoporosis; median progression time was >8.5 years. Progression time was >8.2 years in "low-risk" tertile (T score between -1.1 and -1.6 SD), >8.5 years in "middle-risk" (between -1.6 and -2), and 3.2 years in "high-risk" (from -2 to -2.4) (p<0.0001). CONCLUSIONS: Our results may help to define the BMD testing interval. The lowest T score tertiles would suggest recommending a subsequent DXA in 1-2 years; in the highest tertiles, ≥6 years. Early intervention in patients with bone demineralization could reduce fracture-related morbidity/mortality.

Bone mineralization defects and vitamin D deficiency: histomorphometric analysis of iliac crest bone biopsies and circulating 25-hydroxyvitamin D in 675 patients.

Parathyroid hormone (PTH) is only one measurable index of skeletal health, and we reasoned that a histomorphometric analysis of iliac crest biopsies would be another and even more direct approach to assess bone health and address the required minimum 25-Hydroxyvitamin D [25(OH)D] level. A cohort from the northern European population with its known high prevalence of vitamin D deficiency therefore would be ideal to answer the latter question. We examined 675 iliac crest biopsies from male and female individuals, excluding all patients who showed any signs of secondary bone diseases at autopsy. Structural histomorphometric parameters, including osteoid indices, were quantified using the Osteomeasure System according to ASBMR standards, and serum 25(OH)D levels were measured for all patients. Statistical analysis was performed by Student's t test. The histologic results demonstrate an unexpected high prevalence of mineralization defects, that is, a pathologic increase in osteoid. Indeed, 36.15% of the analyzed patients presented with an osteoid surface per bone surface (OS/BS) of more than 20%. Based on the most conservative threshold that defines osteomalacia at the histomorphometric level with a pathologic increase in osteoid volume per bone volume (OV/BV) greater than 2% manifest mineralization defects were present in 25.63% of the patients. The latter were found independent of bone volume per trabecular volume (BV/TV) throughout all ages and affected both sexes equally. While we could not establish a minimum 25(OH)D level that was inevitably associated with mineralization defects, we did not find pathologic accumulation of osteoid in any patient with circulating 25(OH)D above 75 nmol/L. Our data demonstrate that pathologic mineralization defects of bone occur in patients with a serum 25(OH)D below 75 nmol/L and strongly argue that in conjunction with a sufficient calcium intake, the dose of vitamin D supplementation should ensure that circulating levels of 25(OH)D reach this minimum threshold (75 nmol/L or 30 ng/mL) to maintain skeletal health.

Las alteraciones del metabolismo óseo-mineral pretrasplante no influyen en la evolución inicial del injerto renal / No disponible

Antecedentes: el Retraso en la Función del Injerto (RFI) es uno delos problemas más frecuentes en las primeras semanas del trasplante renal, afectando a su evolución. Conocer los factores de riesgo de RFI puede ayudar a reducir su incidencia. Las alteraciones en los niveles séricos de calcio, fósforo y Hormona Paratiroidea (HPT) son muy frecuentes en los pacientes en lista de espera de trasplante y podrían favorecer la aparición de RFI. Sin embargo, diversos estudios que han analizado la relación entre los niveles pretrasplante de calcio, fósforo y HPT y el desarrollo de RFI han obtenido resultados dispares que no permiten confirmar ni descartar que influyan en el mismo. Métodos: estudiamos los valores pretrasplante de calcio, fósforo y HPT en 449 pacientes trasplantados renales realizados entre 1994 y 2007. Se definió RFI en aquellos pacientes que precisaron diálisis durante la primera semana postrasplante. De las historias clínicas se recogieron los datos clínicos y analíticos relacionados con RFI. Resultados: un 27,3%presentó RFI. Los factores significativos de riesgo para desarrollar RFI fueron la edad del receptor, el tipo y la necesidad de tratamiento sustitutivo renal, el título de anticuerpos anti-HLA máximos, el número de trasfusiones pretrasplante y la edad del donante. No detectamos diferencias significativas en los valores medios de calcio (9,4 ± 1,0 vs. 9,5 ± 0,9 mg/dl, p = 0,667), fósforo(5,7 ± 1,8 vs. 5,5 ± 1,5 mg/dl, p = 0,457), producto fosfocálcico (53,5± 17,2 vs. 51,8 ± 14,6 mg2/dl2, p = 0,413) y HPTi (315 ± 312 vs. 340± 350 pg/ml, p = 0,530) en los pacientes con y sin RFI. Conclusiones: en nuestro estudio, los parámetros séricos pretrasplante del metabolismo óseo-mineral no favorecen el desarrollo de RFI (AU)

Background: abnormalities in serum calcium, phosphate, and Parathyroid Hormone (HPT) concentrations are common in patients with chronic kidney disease and have been associated with increased morbidity and mortality. One of the most common problems in the first weeks after renal transplantation is Delayed Graft Function (DGF). There are several well-known risk factors for DGF development, but the role of calciumphosphate-HPT homeostasis as a risk factor for early graft dysfunction is controversial. This issue was addressed in the current study. Methods: Pretransplant HPT, calcium and phosphate values were gathered in 449patients that received a renal transplant in our center between 1994 and 2007. Other variables expected to influence the risk for delayed graft function wereincluded from the clinical charts. Results: The incidence of DGF was 27.3%. DGF development was significantly associated with recipient age, type and need of renal replacement therapy, peak panel reactive antibodies, transfusion number and donor age. There were no significant differences in the mean pretransplant values of calcium (9.4 ± 1.0 vs. 9.5 ± 0.9 mg/dl, p = 0.667),phosphate (5.7 ± 1.8 vs. 5.5 ± 1.5 mg/dl, p = 0.457),calcium-phosphate product (53.5 ± 17.2 vs. 51.8 ± 14.6mg2/dl2, p = 0.413) and HPT (315 ± 312 vs. 340 ± 350pg/ml, p = 0.530) between patients with and without DGF. Conclusions: In our study population pretransplant serum HPT, calcium and phosphorus levels have no influence on the risk for DGF (AU)

Contribution of bone and mineral abnormalities to cardiovascular disease in patients with chronic kidney disease.

1,25-Dihydroxyvitamin D(3) levels begin to drop early in the course of kidney disease, leading to elevated parathyroid hormone levels and disrupted mineral metabolism. Impaired mineral metabolism seems to be associated not only with bone disease but also with vascular calcification. Animal models have identified molecular mechanisms by which high mineral levels and other uremic substances induce vascular smooth muscle cells to undergo phenotypic changes that initiate the calcification process. Moreover, several epidemiologic and clinical studies showed strong associations between bone loss, arterial calcification, and cardiovascular disease in populations with and without kidney disease. This review discusses evidence that two early complications of chronic kidney disease--vitamin D deficiency and secondary hyperparathyroidism--contribute to bone and cardiovascular disease. New treatment strategies aimed at the prevention of bone loss and parathyroid hyperplasia, such as vitamin D receptor ligand therapy, calcimimetic agents, and noncalcifying phosphate binders, are being investigated for their impact on improving overall outcome in dialysis patients.

Bone mineral density correlation with fractures in nonambulatory pediatric patients.

Although bone mineral density (BMD) as related to T score (comparison with young adult) is well correlated with fracture risk in adults, no such correlation has been confirmed in children. Quadriparetic children have lower BMD than age-matched controls, as well as a higher rate of fragility fracture. This study examines a cohort of children with quadriparesis and other nonambulatory children to correlate BMD with fragility fractures.We hypothesize that fracture in these children is related to BMD as correlated with patient size and that age comparison (Z-score) is less important. Review of all children with a dual-energy x-ray absorptiometry scan from August 2003 to June 2005 identified 101 nonambulatory pediatric patients (excluding children with osteogenesis imperfecta or metabolic bone disease). Sixteen patients had insufficient data, leaving 85 patients, 26 of whom had experienced fragility fractures. Lateral femoral dual-energy x-ray absorptiometry scan was performed on one or both legs, then regions were averaged. Data was evaluated for statistical correlation between BMD and body size as evidenced by body mass index (BMI). Other factors, including age, Z-score, and height and weight independently were secondarily evaluated for correlation with fracture risk. Correlation was demonstrated between history of fracture and BMD when related to BMI (P = 0.002). In conclusion, in these nonambulatory children, the combination of the BMD of the distal femur and BMI correlates well with occurrence of fragility fracture and may relate to fracture risk. This relationship is independent of the child's chronological age and Z-score. This information may be helpful prognostically to define a treatment algorithm for low bone density on a case-by-case basis.

Clinical applications of bone density testing for osteoporosis.

Bone mineral density (BMD) testing is a clinical tool to diagnose osteoporosis or low bone density, predict fracture risk, and monitor changes in bone density over time. Non-invasive measurement of BMD is done with a variety of technologies for many different skeletal sites. Dual-energy X-ray absorptiometry (DXA) is the gold-standard for diagnosing osteoporosis and monitoring changes in BMD over time. Optimal use of DXA requires staff training and standard operating procedures that include quality controls for instrument maintenance, patient education, indications and contraindications for testing, precision assessment, scan acquisition, analysis, interpretation, and reporting. Other technologies, as well as DXA, are used to estimate the risk of fracture. BMD is commonly expressed as a T-score, the standard deviation variance of the patient's BMD compared to a young-normal reference population. In untreated postmenopausal women, there is a strong correlation between T-score and fracture risk, with fracture risk increasing about two-fold for every standard deviation decrease in bone density. BMD in postmenopausal women is classified as normal, osteopenia, or osteoporosis according to criteria established by the World Health Organization. BMD testing, combined with assessment of clinical risk factors for fracture, allows healthcare providers to identify patients who may benefit from pharmacologic therapy to reduce the risk of future fractures. Clinical applications of BMD testing are presented in this review.

Calidad de vida de los pacientes con osteoporosis. Validación de la versión en español de un instrumento específico: el OPTQoL / Quality of life in patients with osteoporosis. Validation of the Spanish version of the Osteoporosis-Targeted Quality of Life Questionnaire

Objetivo: Estudiar la validez y confiabilidad de una versión española del Osteoporosis-Targeted Quality of Life Questionnaire (OPTQoL), un instrumento específico para medir calidad de vida relacionada con la salud (CVRS) en pacientes con osteoporosis (OP).Pacientes y métodos: Estudio transversal. Se incluyó a las pacientes con OP primaria (posmenopáusica o senil) definida por densidad mineral ósea (DMO) en columna lumbar o cuello femoral con T-score < -2,5 desviaciones estándar (DE). Se registraron variables demográficas y de enfermedad y se aplicaron los instrumentos OPTQoL (de 0 a 10, mejor a peor CVRS), SF-36 (de 0 a 10, mejor a peor CVRS), EuroQoL-pefil de salud (de 0 a 2, mejor a peor CVRS) y EuroQol-escala visual (de 0 a 10, mejor a peor estado de salud). Se estudió validez de constructo del OPTQoL (análisis de correlación y regresión con SF-36 y otras variables), capacidad discriminativa entre pacientes con y sin fractura vertebral (prueba de la U de Mann-Whitney), coherencia interna ( de Cronbach), reproducibilidad (prueba test-retest), tiempo empleado y comprensión. Para los análisis de correlación se utilizaron el doble producto momento de Pearson y el coeficiente de correlación de Spearman (test-retest). Se consideró significativo un valor de p < 0,05, sin ajuste para comparaciones múltiples. Resultados: 45 pacientes (43 mujeres) con edad (media ñ DE), 66,3 ñ 6,8 años; tiempo desde la menopausia (mujeres), 20,1 ñ 8,5 años, y T-score en columna lumbar, -3,42 ñ 0,9 DE; 20 (44 por ciento) con fracturas vertebrales. OPTQoL global, 7 ñ 2,1; correlación con SF-36 global, r = 0,69, p < 0,0001. OPTQoL- función física, 6,7 ñ 2,5; correlación con SF-36 función física, r = 0,74, p < 0,0001. OPTQoL adaptaciones, 7,1 ñ 2,1; correlación con SF-36escala física global, r = 0,66, p < 0,0001. OPTQoL miedos, 7,1 ñ 2,1. OPTQoL en pacientes con fracturas, mediana 8,2 frente a 6,3 en pacientes sin fractura, p = 0,0068. Coherencia interna y reproducibilidad test-retest: OPTQoL función física: alfa, 0,84 y rho, 0,95; adaptaciones, 0,85 y 0,98; miedos, 0,82 y 0,96. Tiempo: 5-10 min. Comprensión: buena. Conclusiones: La versión española del OPTQoL es válida, confiable y factible para medir CVRS en pacientes con OP. El deterioro de CVRS en la muestra de pacientes estudiada es importante (AU)

Late-onset spondyloarthropathy mimicking reflex sympathetic dystrophy syndrome.

Atypical presentations are common when spondyloarthropathy develops in older patients. We report two cases initially mistaken for reflex sympathetic dystrophy syndrome (RSDS). Both the patients were men, aged 62 and 75 years, respectively, with marked painful edema of a foot. One patient reported a moderate-energy trauma as the triggering event. Severe diffuse demineralization was noted on radiographs and diffuse hyperactivity on bone scans starting at the early vascular phase. These findings suggestive of RSDS led to treatment with calcitonin, griseofulvin, and pamidronate, all of which were ineffective. Laboratory tests showed severe inflammation, promoting investigations for other conditions. Spondyloarthropathy was diagnosed based on oligoarthritis with sacroiliitis, presence of HLA B27, and a favorable response to non-steroidal antiinflammatory therapy. In older patients, edema of the foot with severe demineralization and the laboratory evidence of inflammation should suggest a spondyloarthropathy.

Spontaneous external auditory canal cholesteatoma complicated by rheumatoid arthritis--case report and review of the literature.

A 63-year-old woman with rheumatoid arthritis sought medical assistance for dull and chronic pain in her left ear two and half years after her initial diagnostic examination. Otoscopic examination revealed that the posteroinferior wall of the bony external ear canal was eroded and that the small cavity was filled with squamous debris. The condition was diagnosed as external auditory canal cholesteatoma (EACC). The existence of EACC might suggest complications of bone disease, aging cerumen gland, or a low migratory rate of the epithelium.

Avances en osteoporosis (XI) / Advances in osteoporosis (XI)

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