The osteoporosis treatment gap in patients at risk of fracture in European primary care: a multi-country cross-sectional observational study.

This study in 8 countries across Europe found that about 75% of elderly women seen in primary care who were at high risk of osteoporosis-related fractures were not receiving appropriate medication. Lack of osteoporosis diagnosis appeared to be an important contributing factor. INTRODUCTION: Treatment rates in osteoporosis are documented to be low. We wished to assess the osteoporosis treatment gap in women ≥ 70 years in routine primary care across Europe. METHODS: This cross-sectional observational study in 8 European countries collected data from women 70 years or older visiting their general practitioner. The primary outcome was treatment gap: the proportion who were not receiving any osteoporosis medication among those at increased risk of fragility fracture (using history of fracture, 10-year probability of fracture above country-specific Fracture Risk Assessment Tool [FRAX] thresholds, T-score ≤ - 2.5). RESULTS: Median 10-year probability of fracture (without bone mineral density [BMD]) for the 3798 enrolled patients was 7.2% (hip) and 16.6% (major osteoporotic). Overall, 2077 women (55%) met one or more definitions for increased risk of fragility fracture: 1200 had a prior fracture, 1814 exceeded the FRAX threshold, and 318 had a T-score ≤ - 2.5 (only 944 received a dual-energy x-ray absorptiometry [DXA] scan). In those at increased fracture risk, the median 10-year probability of hip and major osteoporotic fracture was 11.2% and 22.8%, vs 4.1% and 11.5% in those deemed not at risk. An osteoporosis diagnosis was recorded in 804 patients (21.2%); most (79.7%) of these were at increased fracture risk. The treatment gap was 74.6%, varying from 53% in Ireland to 91% in Germany. Patients with an osteoporosis diagnosis were found to have a lower treatment gap than those without a diagnosis, with an absolute reduction of 63%. CONCLUSIONS: There is a large treatment gap in women aged ≥ 70 years at increased risk of fragility fracture in routine primary care across Europe. The gap appears to be related to a low rate of osteoporosis diagnosis.

Isolated carbapenem resistant bacteria, their multidrug resistant profile, percentage of healthcare associated infection and associated mortality, in hospitalized patients in a University Hospital in Bratislava.

OBJECTIVES: The absence of clinical studies in Slovakia on carbapenem-resistant K. pneumoniae, A. baumannii, and P. aeruginosa, makes planning and treatment strategies challenging and less effective. Our aim is to provide new clinical data on the percentage of healthcare-associated infection, antibiotic resistance profile, and mortality risk associated with these carbapenem-resistant bacteria in our department. METHODS: An observational, prospective, cross-sectional study was performed for a period of 15 months. Strain identification was performed after classical isolation and bio-chemical and cultivation methods. Antibiotic testing results were interpreted according to EUCAST guideline. RESULT: Associated mortality risk was the highest in patients diagnosed with A. baumannii. The urinary tract was the most common site of isolation in all the three types of bacteria. Colistin was shown to be the most potent antibiotic among all the three types of bacteria, followed by aminoglycoside for K. pneumoniae and P. aeruginosa and ampicillin-sulbactam for A. baumannii. CONCLUSION: A. baumannii poses the biggest challenge in the treatment and management of infected patients in our centre in Bratislava. Cephalosporins of the second to fourth generation, quinolones, tetracyclines, and cotrimoxazole are widely ineffective in the treatment of isolated bacteria. Reintroduction of colistin, despite its drug toxicity, can be considered as the last resort treatment I (Tab. 4, Fig. 4, Ref. 30).

Prevalence of sarcopenia among hospitalized internal medicine patients: A cross-sectional single-center pilot study according to EWGSOP2 criteria.

INTRODUCTION: Sarcopenia is associated with a higher risk of adverse outcomes among hospitalized patients with chronic diseases. Currently, an unmet need lies in its low diagnostic yield. We conducted a pilot study with the aim to screen hospitalized patients for sarcopenia using the EWGSOP2 criteria. PATIENTS AND METHODS: A cross-sectional study among hospitalized patients in internal medicine was carried out, inclusion criteria: age>55, ability to stand-up from a chair. EXCLUSION CRITERIA: bed-bound, terminal stages of the disease, ICU stay. We measured hand-grip strength, fat-free mass by bioimpedance and short physical performance battery test (SPPB). Sarcopenia was diagnosed in low hand-grip strength and low muscle mass (EWGSOP2), severe sarcopenia in sarcopenic patients with low physical performance (SPPBT≤8). RESULTS: 40 patients were enrolled, sarcopenia was diagnosed in 8/20 (40%) men and 3/20 (15%) women (p=0.15), severe sarcopenia in 6/20 men (30%) and 2/20 (10%) women (p=0.24). 65% of men and 40% of women had SPPBT≤8, and 60% of men and 55% of women had gait speed≤0.8m/s. CONCLUSION: Among hospitalized internal medicine patients sarcopenia and severe sarcopenia are common, particularly in males. New diagnostic criteria provide a relatively simple and applicable tool for screening among internal medicine inpatients (Tab. 3, Ref. 25).

Lipoprotein particle sizes in patients undergoing kidney transplantation.

Asymptomatic atherosclerotic disease is prevalent in the middle-aged group of kidney transplant recipients. In order to improve the estimation of their cardiovascular risk, dyslipidaemia pattern is very important to be evaluated. Knowledge of the lipid particle spectrum in patients undergoing kidney transplantation could help the clinicians to timely start intervention and prevention of atherosclerosis with an early hypolipidemic statin treatment (Tab. 2, Ref. 20).

Influence of vitamin D on the expression of mRNA of cytokines in the mucosa of inflammatory bowel disease patients.

The aim of this study was to analyze the influence of 25(OH)VD serum concentration on the expression of mRNA cytokines (IL-6, IL-8, IL-12, IL-17, IL-23, TNFα, CCR1, CCR2, CCR5, CCR9, CCL5, TLR2, TLR4, TLR5, CD207 ,CD206, FoxP3) in mucosa of IBD patients. The cohort consisted of 86 IBD patients (48 CD and 38 UC) followed at the IBD center of University Hospital Bratislava-Ruzinov. We performed colonoscopy in each patient and took biopsies from mucosa of sigma and terminal ileum. Serum concentration of 25(OH)VD was assessed at the time of colonoscopy. mRNA was extracted from mucosal biopsy samples for each cytokine. Then we analyzed the correlation between VD and the expression of mRNA of cytokines from biopsies samples.  In CD we observed a significant positive correlation of serum concentration 25(OH)VD and the expression mRNA level of IL-6. There was also trend towards significant positive correlation of the expression mRNA of TNFα, IL-10, IL-23, TLR 2 in inflamed mucosa of terminal ileum as well as the expression mRNA of CCR5 and CCR1 in non-inflamed mucosa from terminal ileum. We also found a trend towards positive correlation between 25(OH)VD and the expression mRNA of IL-23, TLR4, CD 207, CCR1, CCR5 and CD 206 in non-inflamed mucosa of sigma in UC.VD significantly correlated with the levels of expression of several inflammatory cytokines including TNFα in colonic mucosa of patients with IBD (Tab. 4, Fig. 3, Ref. 31).

Speckle tracking can detect subclinical myocardial dysfunction in rheumatoid arthritis patients.

INTRODUCTION: Patients with rheumatoid arthritis (RA) have shorter life expectancy and their risk of cardiovascular death is more than 50 % higher than the rest of the population. Early myocardial dysfunction in RA patients may be detectable sooner using speckle­tracking echocardiography. METHOD: Cross-sectional study enrolled 55 patients with RA (mean age 44.1 years) without known cardiovascular disease and 31 healthy controls. All subjects underwent a standard echocardiographic examination: indexed left ventricular mass, left ventricle ejection fraction, isovolumic contraction and relaxation times (IVCT and IVRT), mitral valve inflow curve (E/A), septal mitral annular motion (e'), and E/e' ratio as well as the speckle tracking assessment of left ventricle longitudinal, radial and circular strain and strain rate. RESULTS: In standard echocardiographic examination RA patients exhibited higher indexed left ventricle mass (96.36±20.90 g/m2 vs 95.84±21.86 %, p=0.013), lower ejection fraction (64.84±3.87 % vs 67.10±3.87 %, p=0.011) and prolonged IVCT (61.51±9.30 ms vs 53.71±8.95 ms, p=0.001). Diastolic dysfunction was demonstrated by prolonged IVRT (81.62±9.56 ms vs 74.58±12.02 ms, p=0.007) as well as by higher E/e' ratio (8.21±1.76 vs 7.21±1.52, p=0.009). Speckle­tracking method detected lower global longitudinal epicardial strain (-19.51 % vs -21.46 %, p=0.049). Radial, circular, and transversal strains and strain rates were same in both groups. Global longitudinal epicardial strain correlated with IVCT and IVRT, disease duration, and markers of myocardial damage NTproBNP. CONCLUSIONS: Standard echocardiographic assessment of myocardial function is examiner- and angle-dependent method with considerable limitations for evaluation of minimal subclinical changes. Speckle-tracking echocardiography significantly revealed incipient myocardial dysfunction in RA patients without overt cardiovascular diseases. This correlates with clinical RA characteristics and markers of cardiac damage (Tab. 4, Ref. 48).

24-hour outpatient ECG as a screening method in patients with primary hyperparathyroidism.

PURPOSE: Patients with primary hyperparathyroidism are characterized by increased calcium plasma concentrations, which in turn could have a potential to induce ECG changes, especially shortening of the QT interval. Therefore, the aim of this study was to evaluate, whether the routine 24-hours outpatient ECG monitoring could be used for screening the primary hyperparathyroidism. METHODS: Totally, 31 patients (mean age, 59.2 ± 12.99 years) with primary hyperparathyroidism were compared to 20 healthy controls. All patients underwent mineral metabolism biochemical evaluation, ultrasound or scintigraphy of the neck, and a 24-hour outpatient ECG. The device detected QT, QTc, and RR intervals during a 24-hour period. RESULTS: Significantly higher calcium concentrations were confirmed in patients when compared to controls (2.38 ± 0.12 vs 2.92 ± 0.29 mmol/l; p < 0.001). However, no significant differences were found between controls and patients in QT interval and overall heart rate. CONCLUSION: Although shortening of the QT interval is a common ECG finding in patients with hyperparathyroidism, it seems that 24-hour outpatient ECG is not suitable for primary hyperparathyroidism screening (Tab. 2, Fig. 4, Ref. 28).

Predictors of blood pressure control in patients with resistant hypertension.

BACKGROUND: Uncontrolled resistant hypertension (RH) defined by the mean 24-hour ambulatory blood pressure (ABPM) represents an independent risk factor in hypertensive patients. Predictors of blood pressure (BP) control in RH are not yet clearly defined. OBJECTIVES: To evaluate the predictors of BP control in RH patients with repeated ABPM measurements. METHODS: 114 consecutive patients from outpatient cardiology office fulfilling criteria for RH (office BP ≥ 140 and/or 90 mmHg, with treatment of ≥ 3 antihypertensive drugs, including diuretic, or controlled BP with > 3 drugs), with two consecutive ABPM studies were compared in clinical characteristics according to BP control assessed by ABPM RESULTS: After the second ABPM, BP was controlled in 25.4 % of patients; the remaining 74.6 % were classified as uncontrolled. In the uncontrolled BP group, systolic office BP was 140.91±16.71 mmHg, diastolic 81.26 ± 10.92 mmHg. In ABPM, systolic was 145.11 ± 13.65 mmHg, diastolic 81.26 ± 10.92 mmHg. Compared to the controlled BP group, in the uncontrolled group the age was higher 72.32 ±10.89 years (p = 0.047), baseline average real variability of systolic BP was lower 12.66 ± 3.08 vs. 14.52 ± 3.53 (p = 0.013), no significant difference in baseline standard deviation of systolic BP changes was found. CONCLUSION: Higher office BP, older age, and increased short term BP variability were associated with an uncontrolled hypertension. Stronger association was found with baseline average real variability rather than standard deviation. No significant differences were found in the dipping status and other clinical characteristics (Tab. 6, Fig. 1, Ref. 28).

Changes in metabolic syndrome parameters after liposuction.

Liposuction - one of the most frequent procedures in cosmetic surgery - is the surgical aspiration of fat from the subcutaneous layer leaving a more desirable body contour and leaving a smooth transition between the suctioned and nonsuctioned areas. Metabolic syndrome is epidemiologically important medical condition that includes insulin resistance, dyslipidemia, central obesity, hypertension, impaired glucose tolerance or diabetes mellitus, and high rates of atherosclerotic disease. According to the latest findings, liposuction reduces the amount of subcutaneous fat, which changes the abdominal - superficial adipose tissue ratio and thus might affect the potential of metabolic syndrome by the means of its separate parameters and clinical manifestations. Results that can be found in the published literature remain controversial and often contradictory, thus leaving enough space for further investigations regarding the relation of these two clinical entities (Ref. 33).

The prevalence and risk factors for osteoporosis in patients with inflammatory bowel disease.

AIM: Osteoporosis is a known chronic complication of inflammatory bowel diseases (IBD). The aim of our study was to describe the prevalence of reduced bone mineral density (BMD) in IBD patients and to identify crucial risk factors for osteoporosis. METHODS: The cohort consisted of 76 IBD patients, 40 with Crohn's disease (CD) and 36 with ulcerative colitis (UC). Clinical characteristics of every patient were recorded, i.e. age, sex, duration of the disease, clinical behavior, location of disease according to Montreal classification, surgeries, steroid medication, sIBDQ, and smoking habits. We examined the serum 25-hydroxyl vitamin D3 (25-OHD3) in each patient. The BMD was determined by dual-energy X-ray absorptiometry (DXA) at the lumbar spine and femoral neck. RESULTS: Osteoporosis was documented in 10 IBD patients (13.2 %), while osteopenia in 35 of them (46.1 %). Patients with CD have significantly lower femoral Z score than patients with UC. Femoral Z score was strongly associated with disease duration, and in CD patients suffering from stricturing form, with ileic or ileocolic location and history of proctocolectomy or total colectomy. Patients with osteoporosis had a significantly lower level of 25-OHD3 than patients with normal BMD. CONCLUSION: Patients with long disease duration and those suffering from stricturing form of CD with ileic/ileocolic location and history of proctocolectomy/total colectomy are at higher risk of developing osteoporosis than other IBD patients. The high proportion of osteopenia/osteoporosis in our study underlines the importance of BMD measurement in all IBD patients as a base for initiating the appropriate treatment (Tab. 1, Fig. 3, Ref. 63).

Effect of growth hormone on bone status in growth hormone-deficient adults.

BACKGROUND: Growth hormone deficiency (GHD) is associated with reduced bone mineral content and increased risk of osteoporotic fractures. Reduced peak bone mass might explain the low bone mineral density (BMD) among patients with childhood onset GHD (CO-GHD) whilst the cause of osteopenia in adult-onset GHD (AO-GHD) is not fully understood. OBJECTIVES: Prospective multicentric study to asses bone status in GHD adults after two years of recombinant growth hormone replacement treatment. METHODS: In 94 GHD adults (49 men; Ø 34.5 yrs) we have measured BMD and bone markers (CTX, osteocalcin) during two years of rhGH treatment (at baseline, after 3 and 6 months, and after 1 and 2 years). Patients were adequately substituted for GHD and other pituitary deficiencies. RESULTS: We have observed an increase in BMD-lumbar spine: n=42, 0.8155 →0.9418 g/cm2, p<0.0001; femoral neck n=41; 0.8468 →0.9031; p= 0.0004; BMD-whole body 1.0179 →1.0774; p=0.0003. We have compared gender difference: BMD-L-spine by 15.8 % in men (n=21) and by 5.6 % in women (n=19) (p= 0.008); BMD-femoral neck increased by 11.03 % in men and by about 3.0 % in women (p=0.032). In women, the initial decrease in BMD was recorded after 3 months. CO-GHD adults yielded a higher increase in BMD -L-spine (16.6 %, p=0.022). A correlation exists between IGF-I levels and BMD in lumbar spine (1st year: R=0.348, p=0.026; 2nd year: R= 0.33, p=0.0081) and between IGF-I and osteocalcin (1st year: R=0.383; p=0.0038). CONCLUSION: Two-year therapy with recombinant human growth hormone improved bone status. IGF-I appears to be a good indicator of rhGH effect on bone (Tab. 3, Fig. 9, Ref. 36). Text in PDF www.elis.sk.

[Thyrostatic treatment and its adverse effects]. / Tyreostatická liecba a jej neziadúce úcinky.

Antithyroid drugs are relatively simple molecules known as thionamides, which contain a sulfhydryl group and a thiourea moiety within a heterocyclic structure. Propylthiouracil (6- propyl 2- sulfanylidene 1,2,3,4- tetrahydropyrimidin4- one) and methimazole (1- metyl 2,3- dihydro1H imidazole 2- thione) are the antithyroid drugs used in the United States. Methimazole is used in most of Europe and Asia, and carbimazole -  methimazole analogue, is used in the United Kingdom and parts of the former British Commonwealth. Their primary effect is to inhibit thyroid hormone synthesis by interfering with thyroid peroxidase mediated iodination of tyrosine residues in thyroglobulin and is an important step in the synthesis of thyroxine and triiodothyronine. Propylthiouracil (but not methimazole or carbimazole), can block the conversion of thyroxine to triiodothyronine within the thyroid and in peripheral tissues. Antithyroid drugs may have clinically important immunosuppressive effects. Side effects of thionamides are usually mild, serious untoward effects are observed in < 5% of cases, more frequently during the initial phases of treatment, when the drug daily dose is higher.

Vitamin D deficiency - a possible link between osteoporosis and metabolic syndrome.

OBJECTIVES: The aim of our study was to evaluate the relationship between bone mineral density (examined by DXA - dual energy x-ray absorptiometry), vitamin D3 levels and the signs of metabolic syndrome. METHODS: We examined 55 subjects (37 women, 18 men, age median 67.8 years) with no history of osteoporosis, suffering from metabolic syndrome (defined as abdominal obesity and more than 2 of other components - arterial hypertension, dyslipidemia and diabetes mellitus or impaired glucose tolerance, according to IDF, 2006). RESULTS: Osteoporosis (T-score less than - 2.5) was found in 32.7 % (15 women and 3 men) and osteopenia (T-score between - 1.5 and - 2.5) in 29 % (13 women and 3 men) of patients. We observed a negative correlation between BMI and fat percentage (examined by DXA) and vitamin D3 levels. Low concentration of vitamin D3 was found in 90 % of patients with median 19.36 ug/l (64 % measured in winter, 36 % in summer, no relationship between vitamin D3 levels and season). We also observed a negative correlation between the low concentration of vitamin D3 and presence of diabetes mellitus as a part of metabolic syndrome. CONCLUSION: The link between osteoporosis and metabolic syndrome could influence the therapeutic approach in both disorders and vitamin D supplementation may play an important role in prevention of these severe conditions (Tab. 5, Fig. 1, Ref. 29).

Prevalence of cleft lip and palate in western Slovakia in the years 2001-2007.

OBJECTIVES: The aim of this study was to investigate the prevalence of orofacial clefts (OC) in live newborns from 2001 to 2007 in Western Slovakia and correlate their occurrence with a number of relevant seasonal and geographical factors and epidemiological trend of this condition. In this study we used retrospective active survey collecting clinical data of 220 children with OC registered and operated at the cleft centre in Bratislava. Our study group included 67 patients from Bratislava region and 151 patients from the remaining Western Slovakia (Nitra, Trnava, Trencín regions). Data of live births was obtained from Health Statistics of the Slovak Republic. RESULTS: Total incidence (TI) of 1.49/1000 live births (LB) in the region of Western Slovakia in 2001-2007 marked a decrease of prevalence compared to 1.64/1000 LB in the years 1985-2000. Bratislava region dominated in total prevalence of 1.82/1000 LB compared to the rest of Western Slovakia regions with 1.37/1000 LB. Most observed cleft type was the CP with 38.6 % frequency, followed by CLP with 35.5 % and CL with a frequency of 24.1 %. The frequency of AM with 1.82 % was the lowest. CONCLUSION: The results showed that the frequency risk rate of a birth of a child with OC was 1 to 671 LB in Western Slovakia. The data proved a higher prevalence of OC in Bratislava region with 1 child with this type of congenital anomaly to 549 LB compared with 1 child with OC to 730 LB in the rest of the Western Slovakia regions (Tab. 7, Ref. 16).

[Toxic hepatitis induced by Polygonum multiflorum]. / Toxicka hepatitida po Polygonum multiflorum.

Toxic liver injury is a common cause of acute hepatitis. Here we report a case of 33-year old female with toxic hepatitis caused by unusual agent- extract of chinese plant Polygonum multiflorum. The patient presented with clinical signs of nausea and icterus and laboratory signs of hepatocellular damage following 2 months of readministration of Polygonum mulltiflorum pills. All other causes of hepatocellular damage were excluded. The causality between hepatocellular damage and Polygonum multiflorum ingestion was supported by early recovery after discontinuation, by international scoring system of causality between drug and hepatotoxicity as well as by similarities with other reports from the literature. Considering the growing popularity of herbal products as nutrition supplements we appeal to caution in using these preparations.

[Endocrine changes in liver disease]. / Endokrinné zmeny pri chorobách pecene.

Liver diseases have an influence on function and morphology of all endocrine glands. Knowledge of these specific changes is important in correct interpretation of pathological clinical and laboratory hormonal symptoms and signs induced by liver disease. We analyze the influence on the thyroid, bone metabolism, adrenocorticotropic axis, gonadal hormones, prolactin and growth hormone.

[The viewpoint of an internist on the problem of an aortoenteric fistula]. / Pohlad internistu na problematiku aortoenterálnej fistuly.

Aortoenteric fistula is an uncommon life-threatening disease; it can be divided into primary and secondary one. Primary aortoenteric fistula is the result of ongoing disease in the aorta and the intestine, secondary one is iatrogenic. Typical symptoms are abdominal pain and gastrointestinal bleeding (two-stage process). The most appropriate diagnostic method is CT aortography, treatment is only surgical. 75-year-old patient was admitted to the 5th Department of Internal Medicine in Bratislava due to progression of renal parameters, the patient had undergone an aortofemoral bypass 4 years ago. During the fourth day of his hospitalization the patient had a massive hematochezia with a shock state. After transient stabilization of the patient, 30 minutes after the first hematochezia, a massive hematemesis appeared and then the patient died. An autopsy has confirmed the secondary aortic-enteral fistula between the duodenum and the aneurysm arising from the aortofemoral bypass.

Effect of long-term oral anticoagulant therapy on bone mineral density and bone turnover markers: a prospective 12 month study.

INTRODUCTION: Vitamin K-dependent posttranslational modification of glutamate to gamma-carboxyglutamate is a biochemical feature of the vertebrate blood-clotting cascade. This conversion activates clotting factors and bone proteins, including osteocalcin, a widely accepted marker of osteoblastic activity. Vitamin K antagonists, such as warfarin, inhibit this process. OBJECTIVE: This study was aimed at evaluating the effect of warfarin treatment on BMD and bone turnover markers and determining the relationship between BMD and bone turnover markers. PATIENTS AND METHODS: Fifty-four warfarin users and 62 age- and sex-matched healthy controls were enrolled in 1-year prospective study. Bone mineral density, bone turnover markers, 25-hydroxyvitamin D, serum and urinary calcium measurements were done at baseline and after 12 months of warfarin treatment. RESULTS: No differences were observed between warfarin-treated and control groups in Ca-S, Ca-dU, ALP-S, 25-OHD and BMD after 12 months.The concentrations of serum CTx (306.48 +/- 29 ng/l) and osteocalcin (16.54 +/- 1.06 ig/l) were significantly lower (p < 0.001 and p < 0.05 respectively) after 12 month in warfarin-treated group compared to control group (403.29 +/- 24.7 ng/l and 22.88 +/- 1.33 ig/l). A significant increase in serum and urinary Ca values (p < 0.05) was observed in patients with oral anticoagulant therapy after 12 month compared to baseline levels. Biochemical markers of bone metabolism did not correlate with BMD in either group. CONCLUSION: The long-term use of coumarin was not associated with decreased bone mineral density in our study, but the significantly lower OC and CTx serum levels in coumarin-treated patients suggest that vitamin K has an influence on bone turnover (Tab. 3, Fig. 2, Ref. 29). Full Text in free PDF www.bmj.sk.

Parathyroid Hormone-Related Changes of Bone Structure.

Parathyroid hormone (PTH) increases the release of serum calcium through osteoclasts, which leads to bone resorption. Primary, PTH stimulates osteoblasts leading to increase RANKL (receptor activator for nuclear factor kappa-B ligand) expression and thus differentiation of osteoclasts. In kidneys, PTH increases calcium and decrease phosphate reabsorption. In kidneys, PTH stimulates 1alpha-hydroxylase to synthesize active vitamin D. Primary hyperparathyroidism (PHPT) is characterized by skeletal or renal complications. Nowadays, the classical form of PHPT is less seen and asymptomatic or subclinical (oligo symptomatic) forms are more frequent. Previously, it was thought that cortical bone is preferably affected by PHPT and that predispose bones to fracture at sites with a higher amount of cortical bone. However, an increased risk of vertebral fractures has been found by most of the studies showing that also trabecular bone is affected. Bone Mass measurement (BMD) at all skeletal sites is advised, but another specific tool for fracture assessment is needed. Trabecular bone score (TBS), an indirect measure of trabecular bone, maybe a useful method to estimate fracture risk. TBS is associated with vertebral fractures in PHPT regardless of BMD, age, BMI and gender. Furthermore, there is an association between TBS and high resolution peripheral quantitative computed tomography (HR-pQCT) parameters in the trabecular and cortical compartment. However, studies considering the effect of PHPT treatment on TBS are more conflicting. Secondary hyperparathyroidism caused by vitamin D deficiency was associated with impaired bone microarchitecture in all age categories, as measured by TBS and Hr-pQCT with further improvement after treatment with vitamin D.

Parathyroid Hormone-Related Changes of Bone Structure.

Parathyroid hormone (PTH) increases the release of serum calcium through osteoclasts, which leads to bone resorption. Primary, PTH stimulates osteoblasts leading to increase RANKL (receptor activator for nuclear factor kappa-B ligand) expression and thus differentiation of osteoclasts. In kidneys, PTH increases calcium and decrease phosphate reabsorption. In kidneys, PTH stimulates 1alpha-hydroxylase to synthesize active vitamin D. Primary hyperparathyroidism (PHPT) is characterized by skeletal or renal complications. Nowadays, the classical form of PHPT is less seen and asymptomatic or subclinical (oligo symptomatic) forms are more frequent. Previously, it was thought that cortical bone is preferably affected by PHPT and that predispose bones to fracture at sites with a higher amount of cortical bone. However, an increased risk of vertebral fractures has been found by most of the studies showing that also trabecular bone is affected. Bone Mass measurement (BMD) at all skeletal sites is advised, but another specific tool for fracture assessment is needed. Trabecular bone score (TBS), an indirect measure of trabecular bone, maybe a useful method to estimate fracture risk. TBS is associated with vertebral fractures in PHPT regardless of BMD, age, BMI and gender. Furthermore, there is an association between TBS and high resolution peripheral quantitative computed tomography (HR-pQCT) parameters in the trabecular and cortical compartment. However, studies considering the effect of PHPT treatment on TBS are more conflicting. Secondary hyperparathyroidism caused by vitamin D deficiency was associated with impaired bone microarchitecture in all age categories, as measured by TBS and Hr-pQCT with further improvement after treatment with vitamin D.