Vertebral Scheuermann's disease in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over.

UNLABELLED: In 27 centres across Europe, the prevalence of deforming spinal Scheuermann's disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8% in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann's, helping the differential diagnosis from osteoporosis. INTRODUCTION: This study aims to assess the prevalence of Scheuermann's disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture. METHODS: In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann's disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl's node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2-L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann's by alternative published algorithms when these used the radiographic signs we assessed. RESULTS: Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann's varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8% with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann's was not associated with BMD of the spine or hip. CONCLUSIONS: Since most of the variation in population impact of Scheuermann's was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.

Age estimation.

While age estimation of unidentified corpses and skeletons for identification purposes has a long tradition in forensic sciences, age estimation of living persons has formed a relatively recent area of forensic research which is becoming increasingly important. The international interdisciplinary Study Group on Forensic Age Diagnostics (AGFAD) issued recommendations for age estimation of living persons for the purpose of criminal, civil, asylum and old-age pension procedures as well as for determining the sex and age of skeletons. In the present work, the authors set out state-of-the art age estimation methods for specific case groups, define minimum requirements for reference studies and specify the need for further research. In addition, ethical and medico-legal aspects as well as issues relating to quality assurance are discussed.

Age estimation of unaccompanied minors. Part II. Dental aspects.

Recent years have brought a worldwide increase in cross-border migration due to a globalized economy and ongoing belligerent conflicts. As a result, the percentage of foreigners among the general population has steadily increased not only in Germany, but also in other countries. This trend has triggered a growing demand for forensic medicine to assess the age of adolescents and young adults. The individuals examined here are unaccompanied minors without valid identification documents who do not know their age or else are suspected of not giving their correct age. The mineralization of third molars is the main criterion for dental age estimation of living subjects in the relevant age group. To date insufficient knowledge has been obtained about how ethnic origin can influence tooth mineralization. This, however, constitutes a restraint on the reliability of age estimates and hence on the forensic value of information essential to legal security. A comparative study was conducted to present comparative data on third molar mineralization in a Caucasoid, Mongoloid and African sample. In conclusion, forensic age estimates of living subjects would be more powerful tools if population-specific standards were applied to evaluations of wisdom tooth mineralization. Since the mineralization of third molars is usually completed by the age of 19 or 20 years, this feature cannot be used to ascertain whether a person has attained the forensically relevant age of 21 years. The question was whether determination based on an orthopantomogram of a combination of features relevant to dental age estimation of adults supplies forensically useful information for ascertaining whether a person has attained 21 years of age. The features considered include the DMFT index of all permanent teeth, the DMFT index of all permanent teeth excluding third molars and the DFT index of third molars projecting beyond the occlusal plane. It can be concluded that an evaluation of the variations of the DMFT index does not by itself yield sufficient data to determine with the accuracy required in criminal proceedings whether a person has attained 21 years of age. An additional X-ray examination of the medial clavicular epiphyseal cartilage is, therefore, strongly recommended when assessing whether a person is over 21.

Age estimation of unaccompanied minors. Part I. General considerations.

In recent years many countries have experienced a sharp increase in the demand for forensic age estimates of unaccompanied minors. In many countries the age thresholds of relevance to criminal prosecution lie between 16 and 22 years. In line with recommendations issued by the Study Group on Forensic Age Diagnostics, for determining the age of live subjects a forensic age estimate should combine the results of a physical examination, an X-ray of the hand and a dental examination which records dentition status and evaluates an orthopantomogram. To assess the age of persons who are assumed to be at least 18 years old, an additional radiographic or CT examination of the collar bones is recommended. Forensic age estimates should take account of the ethnic origin and socio-economic status of the person under examination.

Loss of bone mass and vitamin D deficiency after hematopoietic stem cell transplantation: standard prophylactic measures fail to prevent osteoporosis.

Bone mineral density (BMD) and biochemical markers of bone metabolism were analyzed in 67 adults with ALL (n = 27), AML (n = 14), MDS (n = 6) and CML (n = 20) before and after allogeneic stem cell transplantation (SCT). Median age was 36 years (17-56). Twenty-six out of 53 patients (49%) had osteopenia and osteoporosis before SCT, 21/26 had acute leukemias and 5/26 had chronic myeloid leukemia (CML). T-score before SCTwas -1.23 in patients with acute leukemias and 0.62 in CML patients (P = 0.001). After SCT, a significant loss of BMD was observed in all patients. After 6 months, 24 of 36 evaluable patients (67%) had pathologic BMD, 11 of them (30%) had developed osteoporosis. After 12 months, 20 of 32 evaluable patients (62%) had BMD values below normal and nine of them (28%) had osteoporosis. Increased pyridinium excretion was observed in 12/20 patients (60%) with acute leukemias, but only in 3/13 (23%) with CML (P = 0.014). A prolonged vitamin D deficiency for more than 6 months developed early after SCT in all patients. Patients with acute leukemias frequently have osteopenia and osteoporosis before SCT. After SCT, a further loss of BMD occurs independent from the underlying disease. Standard prophylactic measures are not sufficient to prevent loss of bone mass. Studies on prophylactic interventions are needed to prevent severe osteoporosis in long-term survivors of SCT.

Determinants of the size of incident vertebral deformities in European men and women in the sixth to ninth decades of age: the European Prospective Osteoporosis Study (EPOS).

UNLABELLED: More severe vertebral fractures have more personal impact. In the European Prospective Osteoporosis Study, more severe vertebral collapse was predictable from prior fracture characteristics. Subjects with bi-concave or crush fractures at baseline had a 2-fold increase in incident fracture size and thus increased risk of a disabling future fracture. INTRODUCTION: According to Euler's buckling theory, loss of horizontal trabeculae in vertebrae increases the risk of fracture and suggests that the extent of vertebral collapse will be increased in proportion. We tested the hypothesis that the characteristics of a baseline deformity would influence the size of a subsequent deformity. METHODS: In 207 subjects participating in the European Prospective Osteoporosis Study who suffered an incident spine fracture in a previously normal vertebra, we estimated loss of volume (fracture size) from plane film images of all vertebral bodies that were classified as having a new fracture. The sum of the three vertebral heights (anterior, mid-body, and posterior) obtained at follow-up was subtracted from the sum of the same measures at baseline. Each of the summed height loss for vertebrae with a McCloskey-Kanis deformity on the second film was expressed as a percentage. RESULTS AND CONCLUSIONS: In univariate models, the numbers of baseline deformities and the clinical category of the most severe baseline deformity were each significantly associated with the size of the most severe incident fracture and with the cumulated sum of all vertebral height losses. In multivariate modeling, age and the clinical category of the baseline deformity (crush > bi-concave > uni-concave > wedge) were the strongest determinants of both more severe and cumulative height loss. Baseline biconcave and crush fractures were associated at follow-up with new fractures that were approximately twice as large as those seen with other types of deformity or who previously had undeformed spines. In conclusion, the characteristics of a baseline vertebral deformity determines statistically the magnitude of vertebral body volume lost when a subsequent fracture occurs. Because severity of fracture and number of fractures are determinants of impact, the results should improve prediction of the future personal impact of osteoporosis once a baseline prevalent deformity has been identified.

Incidence of vertebral fracture in europe: results from the European Prospective Osteoporosis Study (EPOS).

Vertebral fracture is one of the major adverse clinical consequences of osteoporosis; however, there are few data concerning the incidence of vertebral fracture in population samples of men and women. The aim of this study was to determine the incidence of vertebral fracture in European men and women. A total of 14,011 men and women aged 50 years and over were recruited from population-based registers in 29 European centers and had an interviewer-administered questionnaire and lateral spinal radiographs performed. The response rate for participation in the study was approximately 50%. Repeat spinal radiographs were performed a mean of 3.8 years following the baseline film. All films were evaluated morphometrically. The definition of a morphometric fracture was a vertebra in which there was evidence of a 20% (+4 mm) or more reduction in anterior, middle, or posterior vertebral height between films--plus the additional requirement that a vertebra satisfy criteria for a prevalent deformity (using the McCloskey-Kanis method) in the follow-up film. There were 3174 men, mean age 63.1 years, and 3,614 women, mean age 62.2 years, with paired duplicate spinal radiographs (48% of those originally recruited to the baseline survey). The age standardized incidence of morphometric fracture was 10.7/1,000 person years (pyr) in women and 5.7/1,000 pyr in men. The age-standardized incidence of vertebral fracture as assessed qualitatively by the radiologist was broadly similar-12.1/1,000 pyr and 6.8/1,000 pyr, respectively. The incidence increased markedly with age in both men and women. There was some evidence of geographic variation in fracture occurrence; rates were higher in Sweden than elsewhere in Europe. This is the first large population-based study to ascertain the incidence of vertebral fracture in men and women over 50 years of age across Europe. The data confirm the frequent occurrence of the disorder in men as well as in women and the rise in incidence with age.

Falls explain between-center differences in the incidence of limb fracture across Europe.

There is important geographic variation in the occurrence of the major osteoporotic fractures across Europe. The aim of this study was to determine whether between-center variation in limb fracture rates across Europe could be explained by variation in the incidence of falls. Men and women, aged 50-79 years, were recruited from population-based registers in 30 European centers. Subjects were followed by postal questionnaire to ascertain the occurrence of incident fractures, and were also asked about the occurrence and number of recent falls. Self-reported fractures were confirmed, where possible, by review of the radiographs, medical record, or subject interview. The age- and gender-adjusted incidence of falls was calculated by center using Poisson regression. Poisson regression was also used to assess the extent to which between-center differences in the incidence of limb fractures could be explained by differences in the age- and gender-adjusted incidence of falls at those centers. In all, 6302 men (mean age 63.9 years) and 6761 women (mean age 63.1 years) completed at least one questionnaire concerning fractures and falls. During a median follow-up time of 3 years, 3647 falls were reported by men and 4783 by women. After adjusting for age and gender, there was evidence of significant between-center differences in the occurrence of falls. There was also between-center variation in the occurrence of upper limb, lower limb, and distal forearm fractures. Variation in the age- and gender-adjusted center-specific fall rates explained 24%, 14%, and 6% of the between-center variation in incidence of distal forearm and upper and lower limb fractures, respectively. Given the constraints inherent in such an analysis, in men and women aged 50-79 years, variation in fall rates could explain a significant proportion of the between-center variation in the incidence of limb fracture across Europe.

Airborne concentration of I-131 in a nuclear medicine laboratory.

This study measures the airborne radioactivity during the handling of millicurie quantities of I-131 in the liquid and capsule form. The data indicate there is significant airborne activity when bottles containing 100--145 mCi of liquid I-131 are opened, and that the Nuclear Regulatory Commission level for airborne activity of I-131 in restricted areas (9 X 10(-9) muCi/ml) is exceeded. However, the airborne activity of I-131 is below the Nuclear Regulatory Commission level for restricted areas when 100-mCi quantities of I-131 in the capsule form are used, or during handling of liquid I-131 in the 20- to 30-mCi range. Thyroid counting is a better method than film badge for monitoring the personnel.

[Diagnostic value of secretin injections in dynamic MR pancreatography]. / Diagnostische Wertigkeit der sekretingestützten dynamischen MR-Pankreatikographie (S-MRP).

PURPOSE: To evaluate the effect of intravenous injections of secretin during MRP procedures. MATERIAL AND METHODS: From 1998 to 2001, 340 patients were examined with MRP. Depending on the native MRI/MRP diagnosis, 110 of them received an injection of secretin followed by multiple MRP's (every 2 minutes) up to 10 min after injection. Diagnosis included healthy persons (n = 23), pancreas divisum (n = 11), chronic pancreatitis (n = 68), and pancreatic tumors (n = 22); some patients had more than 1 diagnosis. Visibility of duct structures and amount of fluid filling of the duodenum after secretin injection were evaluated (dynamic examination) based on a five-point scale. Differences were tested statistically by means of Mc Nemar's test and ROC analysis. RESULTS: The visibility of the pancreatic duct could be increased significantly after secretin injection in all subgroups (p < 0.05). Statistically, it turned out not to be important at what time point after injection the MRP was taken. It was possible to evaluate the excretion rate of the pancreas. In healthy persons and those with pancreas divisum, the fluid filling of the duodenum was significantly higher than in those with chronic pancreatitis or pancreatic tumors. However, this finding alone did not suffice in differentiating between both groups (sensitivity 0.68 and specificity 0.59, respectively). CONCLUSION: The i. v. injection of secretin improves the ability of MRP to evaluate the pancreas by increasing the visibility of the pancreatic duct structures and provides a method to assess the excretion rate of the gland.

[Value of negative oral contrast media in MR cholangiopancreatography (MRCP)]. / Der Stellenwert negativer oraler Kontrastmittel in der MR-Cholangiopancreatographie (MRCP).

PURPOSE: Evaluation of the use of a negative oral contrast material in MR cholangiopancreatography (MRCP). MATERIAL AND METHODS: We performed MRCP in single-shot technique (TSE, TR = 2800 ms, TE = 1100 ms, ETL = 64) in 38 patients before and 20-30 min after oral administration of 300-600 ml of a negative oral contrast material. The visualization ducts and details important for the diagnosis was evaluated in a blinded manner. Ductal diameters were measured. Both sets of images were evaluated qualitatively. RESULTS: The ductal diameters did not change after administration of oral contrast material. In 1/3 of all cases the ductal structures were superimposed by a high signal intensity of fluid in the gastrointestinal tract, especially in the tail of the pancreas. After administration of oral contrast material only in 3 patients could a complete visualization of the ducts not be achieved. In 5 cases, details relevant for the diagnostic decision could be seen only on post-contrast images. The anatomic orientation was not compromised by the absence of signal in the gastrointestinal tract. CONCLUSION: Negative oral contrast material should be given before performing a MRCP to provide non-superimposed visualization of the bile and pancreatic ducts. There is no negative influence of the oral contrast material on the diameter of the ducts.

Forensic age diagnostics of living people undergoing criminal proceedings.

In the German-speaking area, recent years have seen a rapid growth of the need for forensic age estimations. Such need arises, for example, if no verified information on the age of a person suspected of a criminal offence is available; the issue at question in terms of criminal law is whether the person concerned has reached the age of criminal responsibility and whether general criminal law in force for adults is to be applied. The relevant age tresholds in criminal proceedings are 14, 18 and 21 years of age. According to recommendations of the Study Group on Forensic Age Diagnostics, a forensic age estimate should consist of a physical examination, an X-ray of the hand, and a dental examination which records dentition status and evaluates an orthopantomogram. In addition, a radiological or CT examination of the clavicles is recommended to establish whether a person has attained 21 years of age. The present article addresses the influence of ethnic origin on the examined developmental systems.

[Fluorescence microscopic demonstration of eosinophile leucocytes with different fluorochromes (author's transl)]. / Fluorescenzmikroskopische Darstellung eosinophiler Leukocyten mit einer Reihe von Fluorchromen.

A screening program involving blood from men and horse resulted in about 80 fluorochromes admitting microscopic differentiation of eosinophile leucocytes (properly their granules) in blood smears. Fluorescence distinguishes either selective, i. e. only eosinophile cells show fluorescence, or specific, that means, eosinophilic granules exhibit fluorescence differing from non-eosinophilic cells by colour and/or intensity.

[Current musculoskeletal symptoms in peri and postmenopausal women: results of a multicenter population epidemiological study. The EVOS Study Group]. / Aktuelle muskuloskeletale Beschwerden bei peri- und postmenopausalen Frauen: Ergebnisse einer multizentrischen bevölkerungsepidemiologischen Studie. EVOS-Studiengruppe.

Within the European vertebral osteoporosis study four stratified systematic samples of German residents aged 50-79 in Lübeck, Heidelberg, Jena and East Berlin have been drawn. Overall 4628 subjects were included, of whom 4385 were contactable and 3106 (71%) responded to the postal questionnaire enquiring about rheumatic complaints "today". 2348 (54%) followed an invitation to a medical examination in which a specific gynaecological history was taken. The prevalence of current back-, neck- and joint-pain is consistently higher in females than in males in all age groups. Females show a peak prevalence in the age group 55-64. 104/1134 women were pre- or perimenopausal. 1030 women had not had their period for at least 13 months and were classified as "postmenopausal". Neither the menopausal status nor the duration of the postmenopause were statistically significantly associated with the frequency of the three rheumatic complaints.

Forensic age diagnostics of living individuals in criminal proceedings.

Age estimations of living individuals are increasingly important in criminal matters. If doubts arise regarding the age of a person suspected of a criminal offense, forensic age estimation is prompted by the need to ascertain whether the person concerned has reached the age of criminal responsibility and whether general criminal law in force for older juveniles or adults is to be applied. According to the recommendations of the Arbeitsgemeinschaft für Forensische Altersdiagnostik (study group for forensic age diagnostics), age estimates in criminal proceedings should be based on the general physical examination, the X-ray examination of the hand and the odontological examination by a dentist, including dental status and orthopantomogram. In order to improve diagnostic reliability, these methods should always be used in combination, ensuring that each part is performed by forensically trained and experienced experts of the relevant disciplines. In order to demonstrate that the proband has reached the age of 21, an additional X-ray examination or CT scan of the clavicles is recommended. Future research projects should assess the variation for a combination of the above methods, quantify the impact of socio-economic status and ethnicity on the examined development systems and review the suitability of non-ionizing imaging methods of age estimation.

[Bone density of spongiosa and cortical bone of the lumbar spine. Relations to sex, age and spinal deformities in a regional collective of the European Study of Vertebral Osteoporosis (EVOS)]. / Knochendichte von Spongiosa und Kortikalis der Lendenwirbelsäule. Beziehungen zu Geschlecht, Alter und Wirbeldeformitäten in einem regionalen Kollektiv der europäischen Studie zur vertebralen Osteoporose (EVOS).

BACKGROUND AND METHOD: In an additional bone density measurement protocol to the European Vertebral Osteoporosis Study (EVOS) separate spongious and cortical density measurements (sQCT) were carried out at the first 3 lumbar vertebrae in 293 volunteers (92 men and 201 women) in 3 Berlin regional centers. RESULTS: The spongious mineral density decreases from proximal to distal (L1 to L3), the cortical density increases from proximal to distal, mainly in men. Men showed no significant decrease of cortical density and a lower decrease of spongious density with age compared to women. A comparison of bone mineral density with vertebral height indices of McCloskey/Kanis, Eastell/Melton and Felsenberg showed significant differences of spongious density between a group with normal vertebral height and a group with at least one pathologically degraded vertebra. Individuals with osteoporosis according to the WHO-definition showed a higher prevalence of vertebral deformities. No significant loss of cortical density was observed in these people.

Reference study on the time frame for ossification of the distal radius and ulnar epiphyses on the hand radiograph.

Hand radiographs from 554 male and 288 female subjects aged 10-30 years, which had been taken due to traumatological indications, were evaluated. A classification into five ossification stages was applied to assess the epiphyseal development of distal radius and distal ulna (1: epiphysis not ossified; 2: epiphysis ossified, nonunion of the epiphysis and metaphysis; 3: partial union of the epiphysis and metaphysis; 4: complete union of the epiphysis and metaphysis, epiphyseal scar visible; 5: complete union of the epiphysis and metaphysis, epiphyseal scar nondiscernable). It was established that male subjects with an ossification stage 4 of the radius or ulna and female subjects with an ossification stage 5 of the radius were at least 14 years old. The occurrence of ossification stage 5 of the radius proves that a male individual has reached the age of 18 years.

Study of age dependence of epiphyseal ossification of the hand skeleton.

Radiological analysis of the hand skeleton is a key pillar of forensic age diagnostics in living subjects undergoing criminal proceedings. The present study investigated whether ossification stage classification of selected epiphyses of the hand could provide added value to hand radiograph analysis. Hand radiographs from 265 male and 164 female subjects aged 10-18years old who had been X-rayed due to traumatological indications were therefore assessed. Epiphyseal ossification of selected elements of the hand skeleton (ulna, radius and third metacarpal, basal phalanx, mesophalanx and telephalanx) was graded based on the criteria of the five-stage classification system of Schmeling et al. (Int J Legal Med, 118:5-8, 2004) for clavicular epiphyseal cartilage. Stage 5 (absence of the epiphyseal scar) does not occur in the radius of men before the age of 18. Stage 5 can therefore be regarded as a potential parameter for valid determination of a minimum age of 18 years for forensic age estimation in criminal proceedings.

Criteria for age estimation in living individuals.

This paper presents updated recommendations of the Study Group on Forensic Age Diagnostics for age estimations in living individuals in criminal proceedings. In order to increase the diagnostic accuracy and to improve the identification of age-relevant developmental disorders, a physical examination, an X-ray examination of the left hand, as well as a dental examination including the determination of the dental status and an X-ray of the dentition should be performed in each case. If the skeletal development of the hand is completed, an additional radiological examination of the clavicles should be carried out. Minimum requirements for reference studies are defined and recommendable studies are listed. Instructions for the examination and the preparation of expert reports are presented. The committee of the study group organizes annual proficiency tests for quality assurance.