Mariana Salamoun

Hypovitaminosis D in healthy schoolchildren.

Background. Vitamin D is essential for skeletal growth, but there are currently no guidelines for vitamin D supplementation after infancy. This study investigates vitamin D insufficiency in healthy children. Methods. Children ages 10 to 16 years from 3 private schools in Beirut, Lebanon, with differing socioeconomic status (SES) were studied: 169 in the spring of 1999 and 177 in the following fall; 83 students participated in both study phases. They had a physical examination, answered a dietary questionnaire, and blood was drawn for calciotropic hormones and indices of bone turnover. Results. Overall, 52% of the students were vitamin D-insufficient; the proportion of insufficiency was 65% in the winter and 40% at the end of the summer. During both seasons, girls had lower vitamin D levels than did boys; those who followed the dress code of covered head, arms, and legs had the lowest levels. Students in the mid-SES school had lower 25-hydroxyvitamin D (25-OHD) levels than did the ones from the high-SES school. After adjusting for confounders, gender, SES, and body mass index remained the significant predictors of vitamin D levels in both seasons (R 2 = 0.53, for spring and 0.28 for fall). There was a significant inverse correlation between 25-OHD levels and parathyroid hormone levels that was best fitted by a curvilinear model (R 2 = 0.19). Conclusion. Even in a sunny country, hypovitaminosis D is common in schoolchildren, more so in the winter. Girls, especially those with a lower SES, are at particular risk. The inverse changes in parathyroid hormone suggest that insufficient vitamin D levels may deleteriously affect skeletal metabolism in healthy adolescents. Vitamin D insufficiency may be prevalent in many other countries where supplementation of milk with vitamin D is not mandatory. Our results call to a reconsideration of vitamin D supplementation in high-risk adolescents to further optimize skeletal health. vitamin D insufficiency, bone metabolism, nutrition, gender, socioeconomic status.

Low calcium and vitamin D intake in healthy children and adolescents and their correlates.

Background: Optimal dietary calcium and possibly vitamin D intake throughout childhood and adolescence may enhance bone mineral accrual. Little data on the intake of these nutrients in Mediterranean countries exist, and predictors of their suboptimal intake are not well defined.Objective: To evaluate systematically the effect of gender, lifestyle factors, and socioeconomic status on mean calcium and vitamin D intake in healthy school children and adolescents from Lebanon.Design: A total of 385 students aged 10–16 y were selected from four public and four private schools between Fall 1999 and Spring 2000. Information on calcium and vitamin D intake, through a semiquantitative food frequency questionnaire that was validated against a 7-day daily record, and on socioeconomic and lifestyle factors were obtained.Results: Only 12% of the students met the adequate intake (AI) recommendation of 1300 mg of calcium/day, and only 16% met the AI recommendation of 200 IU of vitamin D/day. Boys had a significantly higher mean daily calcium intake than girls. Socioeconomic status as assessed by childrens pocket money was a predictor of higher calcium and vitamin D intake. Eating breakfast and physical activity were other correlates of daily calcium and vitamin D intake.Conclusions: Only a minority of students in our study met the AI for calcium and vitamin D. Gender, lifestyle factors, and socioeconomic status were significant predictors of calcium and vitamin D intake. Our findings have important implications regarding the institution of dietary public health strategies to promote skeletal health in Mediterranean countries during a critical time for bone mass accrual.

Low peak bone mineral density in healthy lebanese subjects

Osteoporosis is a major public health problem in Western countries and is projected to have a similar impact in the Middle East. It has been suggested that peak bone mineral density (BMD), a major determinant of osteoporotic fractures later in life, may be lower in this part of the world compared with the Western world. However, subjects have not been randomly selected or systematically screened to rule out secondary causes of bone loss. The purpose of this study was to determine peak bone mass and lifestyle risk factors for bone loss in a randomly chosen sample of healthy Lebanese subjects from the greater Beirut area. Subjects 25-35 years of age were randomly selected from greater Beirut, which comprises one third of the Lebanese at large, and studied during the Fall of 1999. BMD was measured at the lumbar spine, hip, forearm, and total body. A questionnaire on lifestyle factors was administered to all subjects. Results were compared with the database of subjects from the USA provided by the manufacturer, and to the NHANES database for the total hip. Two hundred thirteen subjects were studied; 45 subjects rotated at all three centers for cross-calibration purposes. Peak BMD in Lebanese subjects was 0.2-0.9 SD below that of peak BMD in American subjects, depending on skeletal site, gender, and densitometer. These differences persisted after attempting to adjust for body size. Osteoporosis and osteopenia were more prevalent than in healthy young Americans. Height, weight, and total body fat were the most significant correlates of BMD/bone mineral content (BMC), accounting for 0.3-0.7 of the variance in bone mass measurement. Lifestyle factors had a very modest but significant contribution to bone mass variance. This is the first population-based study from the Middle East demonstrating that peak BMD is slightly lower in Lebanese subjects compared as with an established database from the USA. Due to the selection of relatively healthier subjects in our study than in the NHANES study, the actual differences between the two populations may be even greater. The impact of our findings on the epidemiology of osteoporotic fractures in Lebanon remains to be determined.

Effect of gender, puberty, and vitamin D status on biochemical markers of bone remodedeling

Peak bone mass, a determinant of osteoporosis at older ages, is affected by genetic, nutritional, lifestyle, and hormonal factors. Adolescence is a critical time for peak bone mass accrual, and boys achieve a higher peak bone mass than girls. We have reported vitamin D insufficiency in adolescents in our population, but its impact on bone remodeling is unclear. We systematically evaluated the impact of puberty, gender, and vitamin D status on biochemical markers of bone remodeling. Serum osteocalcin (OC), bone alkaline phosphatase (BAP), C-terminal telopeptide of type I collagen crosslinks (S-CTX), and 25 OH vitamin D were measured in 172 healthy students from private schools in the fall of 1999: There were 92 girls and 80 boys, age 10-17 years. In girls, all markers of bone turnover changed significantly with pubertal stage, were maximal at midpuberty, and decreased toward adult levels by Tanner stage V. Conversely in boys, these markers increased during early pubertal stages but had not normalized by Tanner stage V. Levels of all biochemical markers were significantly higher in boys compared to girls even after adjustment for age, body weight, and Tanner stage, P < 0.0001. In the subgroup of girls, those with vitamin D insufficiency, serum levels of BAP and S-CTX were highest. However, in multiple regression analyses, gender was the only consistent correlate of all three markers of bone remodeling. In conclusion, after adjusting for age, weight, and Tanner stages, changes in bone remodeling markers were most powerfully affected by gender. The latter may have important implications on gender differences in peak bone mass.

Incidence of urinary tract infection following transrectal ultrasound guided prostate biopsy at a tertiary-care medical center in Lebanon

OBJECTIVE To determine the incidence of urinary tract infections (UTIs) following transrectal ultrasound guided needle biopsy of the prostate (TRUBP) and the bacteriology of these infections. DESIGN Retrospective evaluation of the charts and records of all patients who underwent TRUBP between June 1, 2002, and August 31, 2003. SETTING American University of Beirut Medical Center, a tertiary-care center in Lebanon. PATIENTS Two hundred seven patients underwent TRUBP. All received prophylactic antibiotics. One hundred twenty (58%) received ciprofloxacin alone, whereas 87 (42%) received both ciprofloxacin and gentamicin. Sixty-one patients (29.5%) had an enema prior to the procedure, whereas 146 (70.5%) did not. RESULTS Thirteen patients (6.3%) were admitted with UTI. All had rigors and fever on admission. Symptoms appeared at a mean of 2.7 days and the mean hospital stay was 9.2 days. The mean duration of antibiotic treatment was 23.2 days. Ten (77%) of the patients had positive bacteriology. Urine cultures were positive in 8 (61.5%) of the patients and blood cultures in 6 (46.2%). All positive cultures grew Escherichia coli resistant to ciprofloxacin, with 5 isolates producing extended-spectrum betalactamases. CONCLUSIONS TRUBP continues to be associated with significant infectious complications, especially UTI. Given the increasing incidence of antibiotic resistance mainly among the Enterobacteriaceae, antimicrobial prophylaxis practices should be reevaluated and the universal administration of quinolones alone or in combination with aminoglycosides should be reconsidered.

An audit of bone densitometry practice with reference to ISCD, IOF and NOF guidelines

IntroductionThe impact of osteoporosis guidelines on clinical practice has not been fully evaluated.Objectives To estimate the positive predictive value (PPV) of the National Osteoporosis Foundation (NOF), the International Osteoporosis Foundation (IOF) and the International Society for Clinical Densitometry (ISCD) guidelines for osteoporosis and compare it to the PPV of clinical judgement alone.MethodsAll subjects tested for bone mineral density during the fall of 2001 in three teaching hospitals in Beirut were invited to participate. The reference databases used for the calculation of the T-score were the NHANES database for the hip and the manufacturer’s database for the spine. The impact of using guidelines was measured by the increment in PPV. Osteoporosis was defined as a T-score ≤−2.5 at either the spine or hip.ResultsA total of 307 post-menopausal women were tested with dual-energy X-ray absorptiometry (DXA). In current practice (clinical judgement alone), the PPV for osteoporosis was 42.4%; using NOF guidelines, 236 women would have been tested, and the PPV would have been 46.2%. Similarly, using IOF or ISCD guidelines, 236 women would have been tested, and the PPV would have been 47.1%.Conclusion Compared to current clinical practice, application of the ISCD, IOF and NOF guidelines may increase the predictive value of a central DXA for osteoporosis.

Hip Fractures in Lebanese Patients: Determinants and Prognosis

Hip fractures are the most costly of osteoporotic fractures, but little is known about their epidemiology in the Middle East. Hip fracture patients and controls with osteoarthritis admitted to our institution from 1992 to 2002 were studied. Information on gender, age, type of fracture, comorbid conditions, and medications use was obtained. The mean age for hip fracture patients (n = 274) was 72.1(8.5) yr, and for controls (n = 112), it was 71.1(4.4) yr, two-thirds of fractures occurred in women. Fractures were 59% intertrochanteric, 34% femoral neck, and 7% subtrochanteric, with no gender differences. Hip fracture patients were more likely to have had a prior fracture and to suffer from neurological, gastrointestinal, or renal comorbidities, as compared to controls. Less than 10% of hip fracture patients received any therapy for osteoporosis, either on admission or discharge. In a subset of patients with follow-up, the mortality rate was 47% in subjects with hip fracture, and most deaths occurred within the first year postoperatively. Gender but not fracture type affected mortality. Lebanese patients with hip fractures are younger, more likely to sustain intertrochanteric fractures, and experience higher mortality than Western counterparts. Few subjects received osteoporosis therapy. This study carries important public health implications on the management of hip fracture in subjects from Lebanon and, possibly, the Middle East.

Correlates of early assessment of neurodevelopmental disorders in Lebanon

Children with neurodevelopmental disorders who receive early therapeutic interventions present a better developmental pathway than children who do not. Early assessment of neurodevelopmental disorders is the first step in this process. This study aims at describing the variables that are in play in the first assessment of children with autism spectrum disorder (ASD) or intellectual developmental disorders (IDD) in a mental health clinic in Beirut Lebanon. A total of 209 charts covering a period of two years were analysed. Demographic and clinical variables influencing early assessment of neurodevelopmental disorders were found similar to those identified in the international literature with one critical exception, the age at assessment. The average age for diagnosing ASD was four years and seven months and seven years and five months for diagnosing IDD. This finding supports the need for developing a comprehensive national strategy for the early identification of neurodevelopmental disorders.

Densitometer type and impact on risk assessment for osteoporosis.

Studies have shown a high correlation between measurements of bone mineral density (BMD) obtained on differentdual-energy X-ray absorptiometry machines. Challenger osteodensitometers (Diagnostic Medical System [DMS],Montpellier, France) are becoming widely used but little is known about their clinical performance. The aim of this study was to compare BMD measurements and the resulting patient classification based on T-scores obtained on a DMS Challenger device to those obtained on Hologic 4500A (Bedford, MA) device. Fifty-three volunteers were studied. The BMD of the spine and of the hip were simultaneously measured on both densitometers. BMD values obtained on the Challenger were significantly higher than those obtained with the Hologic QDR4500 (p<0.001). The correlations coefficients between the Hologic QDR4500 and the DMS Challenger measured BMDs were r=0.70 at the femoral neck, r=0.70 at the trochanter, and r=0.83 at the spine (p<0.001). Among the 35 postmenopausal women, there was discordance in the WHO T-score-based classification in 28 subjects (80%) at the spine, 18 subjects (52%) at the femoral neck, and 14 subjects (42%) at the trochanter. The intermachine agreement was low: The kappa score was -0.10 at the spine, 0.2 at the femoral neck, and 0.3 at the trochanter. In conclusion, this study cautions against the use of non established densitometers that leads to underdiagnosis of patients and, subsequently, to inappropriate treatment strategies.