Maura Arosio

Beneficial Metabolic Effects of Prompt Surgical Treatment in Patients with an Adrenal Incidentaloma Causing Biochemical Hypercortisolism

CONTEXT In patients with adrenal incidentalomas, subclinical hypercortisolism (SH) is associated with an increased prevalence of the metabolic syndrome. The effect of surgical/conservative approach is debated. OBJECTIVE The objective of the study was to determine the effect of the surgical and conservative approaches on the metabolic syndrome in patients with adrenal incidentalomas. DESIGN This was a retrospective longitudinal study (18-48 months follow-up). SETTING The study was conducted on an in- and outpatient basis. PATIENTS One hundred eight patients with adrenal incidentalomas were studied for the presence of SH, which was diagnosed in the presence of more than two of the following: urinary free cortisol greater than 70 microg per 24 h (193 nmol per 24 h), cortisol after 1 mg dexamethasone suppression test greater than 3.0 microg/dl (83 nmol/liter), ACTH less than 10 pg/ml (2.2 pmol/liter). INTERVENTIONS Surgery was performed in 25 patients with SH (group TrSH+) and 30 without SH (group TrSH-), whereas the conservative approach was chosen by 16 patients with SH (group UntrSH+) and 37 without SH (group UntrSH-). MAIN OUTCOME MEASURES During the follow-up, the improvement/worsening of body weight, blood pressure, or glucose and cholesterol levels was defined in the presence of a greater than 5% weight decrease/increase and following the European Society of Cardiology or the Adult Treatment Panel III criteria, respectively. RESULTS In group TrSH+, weight, blood pressure, and glucose levels improved (32, 56, and 48%, respectively) more frequently than in group UntrSH+ (12.5%, P = 0.05; 0.0%, P < 0.0001; 0.0%, P = 0.001; and 0.0%, P = 0.0014, respectively). In group UntrSH+, blood pressure, glucose, and low-density lipoprotein levels worsened more frequently (50.0, 37.5, and 50.0%, respectively) than in group TrSH+ (0.0%, P < 0.0001; 0.0%, P = 0.001; and 20.0%, P = 0.05, respectively). CONCLUSIONS Regarding the various components of the metabolic syndrome, in patients with adrenal incidentalomas and SH, surgery is beneficial.

Subclinical Hypercortisolism among Outpatients Referred for Osteoporosis

Context The Cushing syndrome is a well-recognized secondary cause of osteoporosis. Contributions The researchers looked for hypercortisolism in asymptomatic patients referred for osteoporosis testing. They identified 7 patients with the condition. Six had functioning adrenal masses and 1 had an adrenocorticotropic hormonesecreting pituitary adenoma. The prevalence of subclinical hypercortisolism among patients with T-scores of 2.5 or less and vertebral fractures was 10.8%. Caution The findings come from a referral setting and might not apply to patients in the community. Implication Subclinical hypercortisolism may be more common than is generally recognized in patients with osteoporosis. The Editors Hypercortisolism is a frequent cause of secondary osteoporosis (1). Overt endogenous hypercortisolism (Cushing syndrome) is a well-recognized cause of osteoporosis (2), but because its prevalence in the general population is low (1 per 500000 persons) (2), its contribution to osteoporosis in general populations is trivial. The terms subclinical Cushing syndrome and subclinical hypercortisolism describe altered adrenocorticotropic hormone (ACTH)cortisol homeostasis without the classic signs or symptoms of the Cushing syndrome (3). Subclinical hypercortisolism is more common than overt hypercortisolism, with an estimated prevalence of about 0.8 per 1000 individuals in the general population (3); however, this prevalence is probably underreported because of the lack of symptoms or signs in these patients (37). Several cross-sectional and longitudinal studies have suggested that these patients are at high risk for complications of hypercortisolism, such as diabetes and osteoporosis (816). Recent studies have indicated that subclinical hypercortisolism is more prevalent than previously thought in patients with type 2 diabetes (1719). However, studies on the prevalence of subclinical hypercortisolism in patients with osteoporosis are lacking. Some evidence suggests that osteoporotic fractures may be the presenting manifestations of otherwise-asymptomatic hypercortisolism (20). Moreover, a recent paper showed a difference in cortisol secretion between healthy participants and patients with established osteoporosis, possibly due to mild autonomous cortisol hypersecretion in some individuals (21). Thus, the prevalence of subclinical hypercortisolism in patients with osteoporosis may be underestimated. We therefore designed a study to assess the prevalence of subclinical hypercortisolism in patients referred to our outpatient clinics for evaluation of osteoporosis. Methods Setting and Participants The study was done at the Casa Sollievo della Sofferenza Scientific Institute, San Giovanni Rotondo, Foggia, Italy, and the San Giuseppe-Fatebenefratelli Hospital, Fatebenefratelli Research Association, Milan, Italy, from January 2005 to December 2005. We recruited 219 consecutive patients (200 women and 19 men) referred to our outpatient clinics for prevention or diagnosis and treatment of osteoporosis and who met the following inclusion criteria: 1) absence of any known secondary causes of osteoporosis (that is, past or current thyrotoxicosis, bowel disease, precocious or surgical menopause, chronic renal failure, chronic hepatic disease, eating disorders, or rheumatologic or hematologic disease); 2) absence of depression and alcoholism, which may enhance cortisol secretion; 3) no administration of drugs influencing bone, cortisol, and dexamethasone metabolism or cortisol secretion; and 4) no signs or symptoms of cortisol excess, including moon facies, striae rubrae, skin atrophy, or buffalo hump. All participants signed consent forms, and local ethical committees approved the study in accordance with the second Declaration of Helsinki. Testing Sequence The Figure shows the study flow diagram. All patients had spinal and femoral dual-energy x-ray absorptiometry and spinal radiography. They had outpatient testing for secondary causes of osteoporosis (general chemistry profile, calcium homeostasis measurements [serum calcium, phosphorus, alkaline phosphatase total activity, 24-hour urinary calcium], thyroid-stimulating hormone, antigliadin antibodies, and serum testosterone in men) and blood for cortisol measurement drawn at 8:00 a.m. after a 1-mg overnight dexamethasone suppression test. Participants with altered thyroid-stimulating hormone levels were tested for free thyroxine, antithyroglobulin, and antithyroperoxidase antibodies; those with high serum calcium levels were tested for serum parathyroid hormone. In patients with normal antigliadin antibodies but clinical suspicion of celiac disease, antiendomysial antibodies were also measured. Figure. Study flow diagram. All patients were subdivided on the basis of bone mineral density (BMD) (T-score of 2.5 or less [low BMD] or greater than 2.5 [normal BMD]) and vertebral fractures. ACTH = adrenocorticotropic hormone; Fx+ = presence of vertebral fractures; Fx = absence of vertebral fractures. Participants with serum cortisol levels greater than 50.0 nmol/L after the 1-mg overnight dexamethasone suppression test were hospitalized for further diagnostic investigations (case participants). Those with cortisol levels less than 50.0 nmol/L had no further evaluation, but antiosteoporotic therapy was started in those with osteoporosis. Among hospitalized patients, catheters were inserted in the forearm vein on the day of admission, and blood testing began the day after to avoid stress-related hypopituitaryadrenal axis activation due to venipuncture. Because inpatient status can in theory increase cortisol secretion (19), a control group of inpatients was recruited to estimate the prevalence of subclinical hypercortisolism in hospitalized participants (control participants). This group comprised 56 age- and sex-matched inpatients without diabetes, osteoporosis, or vertebral fractures who were consecutively hospitalized from January 2005 to December 2005. All hospitalized participants had serum cortisol levels measured at 9:00 a.m. after 2 days of low-dose (0.5 mg every 6 hours) dexamethasone suppression and at midnight, 2 measurements of 24-hour urinary free cortisol, and measurement of ACTH at 8:00 a.m. Subclinical hypercortisolism was diagnosed if participants had incomplete suppression of cortisol (>50.0 nmol/L) after the low-dose dexamethasone suppression test and a 24-hour urinary free cortisol level greater than 165.6 nmol/d (normal range, 22.2 to 165.6 nmol/d) and/or midnight cortisol level greater than 207 nmol/L (normal range, 0.0 to 138.5 nmol/L) (3, 7, 8, 2123). The cutoff value of 165.6 nmol/d for urinary free cortisol corresponds to the 97th percentile value of 70 healthy control participants (20 men and 50 women; age, 35 to 65 years; body mass index, 20 to 40 kg/m2) who were recruited in our center as a reference population for urinary free cortisol. The cutoff value of 207.0 nmol/L for midnight cortisol is the standard for diagnosing hypercortisolism when overt Cushing syndrome is clinically suspected (2). Terzolo and colleagues (24) proposed a cutoff value of 148.8 nmol/L for diagnosing subclinical hypercortisolism, but we used the greater value because we lack reference midnight cortisol values in our center and wanted to increase specificity. Participants with subclinical hypercortisolism and an ACTH level of 2.2 pmol/L or less (normal range, 1.1 to 11.0 pmol/L) had abdominal computed tomography. Patients with subclinical hypercortisolism and ACTH levels greater than 2.2 pmol/L had abdominal computed tomography, nuclear magnetic resonance of the pituitary region, and additional biochemical tests (serum cortisol measurement after 8-mg overnight dexamethasone suppression and serum ACTH and cortisol measurement after stimulation with corticotropin-releasing hormone). Whole-body computed tomography was done when an ectopic source of ACTH hypersecretion was suspected (25). Subclinical hypercortisolism in patients with type 2 diabetes can be attributed mainly to adrenal masses (19). Because incidentally discovered adrenal lesions (adrenal incidentalomas) are frequently found in otherwise-healthy persons (4), we performed abdominal computed tomography in a subset of patients who tested positive after the 1-mg overnight dexamethasone suppression test but were classified as having no subclinical hypercortisolism. Testing Procedures In all patients, bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (Hologic Discovery, Bedford, Massachusetts) at the spine (in vivo precision at L1 to L4, 1.0%) and total and femoral neck (in vivo precision, 1.8% and 2.3%, respectively). Individual BMD values were expressed as SD units (T-scores) relative to the reference population of our center, which included 382 healthy female participants (26). Conventional spinal radiographs in lateral (T4 to L4) and anteroposterior (L1 to L4) projections were obtained in all participants by using a standard technique. Two trained radiologists who were blinded to BMD and hormonal data independently reviewed the radiographs. Vertebral fractures were diagnosed on visual inspection by using the semiquantitative method described by Genant and colleagues (27), in which fractures assessed on lateral thoracolumbar spine radiographs were defined as a reduction of more than approximately 20% in anterior, middle, or posterior vertebral height. Fractures were graded by severity and were graded as I, II, or III on the basis of the height reduction (20% to 25%, 25% to 40%, or >40%, respectively). The radiologists discussed questionable cases for consensus on a diagnosis; the interrater reliability between the 2 radiologists was good (= 0.85). The 2-day, low-dose dexamethasone suppression test was done after ACTH, 24-hour urinary free cortisol, and midnight cortisol levels were measured. Every 6 hours, 0.5 mg of dexamethasone was administrated orally, and serum cortisol was measured at 9:00 a.m., 4

Cortisol Secretion in Patients With Type 2 Diabetes Relationship with chronic complications

OBJECTIVE—The presence of an enhanced cortisol secretion in patients with type 2 diabetes is debated. In type 2 diabetic subjects, cortisol secretion was found to be associated with the complications and metabolic control of diabetes. We evaluated cortisol secretion in 170 type 2 diabetic subjects and in 71 sex-, age-, and BMI-matched nondiabetic subjects. RESEARCH DESIGN AND METHODS—In all subjects, we evaluated ACTH at 8:00 a.m. in basal conditions and serum cortisol levels at 12:00 p.m. (F24) and at 9:00 a.m. after a 1-mg overnight dexamethasone suppression test and 24-h urinary free cortisol (UFC). In diabetic patients, we evaluated the presence of chronic complications (incipient nephropathy, asymptomatic neuropathy, background retinopathy, and silent macroangiopathy). Patients were subdivided according to the absence (group 1, n = 53) or presence (group 2, n = 117) of diabetes complications. RESULTS—In group 2, UFC (125.2 ± 4.6 nmol/24 h) and F24 (120.6 ± 4.1 nmol/l) were higher than in group 1 (109.2 ± 6.8 nmol/24 h, P = 0.057, and 99.7 ± 6.1 nmol/l, P = 0.005, respectively) and in nondiabetic patients (101.7 ± 5.9 nmol/24 h, P = 0.002, and 100.3 ± 5.3 nmol/l, P = 0.003, respectively). In diabetic patients, the number of complications was associated with F24 (R = 0.345; P < 0.0001) and diabetes duration (R = 0.39; P < 0.0001). Logistic regression analysis showed that the presence of diabetes complications was significantly associated with F24, sex, duration of diabetes, and glycated hemoglobin. CONCLUSIONS—In type 2 diabetic subjects, hypothalmic-pituitary-adrenal activity is enhanced in patients with diabetes complications and the degree of cortisol secretion is related to the presence and number of diabetes complications.

Bone Mineral Density, Prevalence of Vertebral Fractures, and Bone Quality in Patients with Adrenal Incidentalomas with and without Subclinical Hypercortisolism: An Italian Multicenter Study

CONTEXT In patients with adrenal incidentalomas and subclinical hypercortisolism (SH), the factors influencing bone and the prevalence of vertebral fractures are debated. Spinal deformity index (SDI), which reflects bone quality, has never been evaluated. OBJECTIVE The objective of the study was to investigate in these patients SDI and factors influencing the prevalence of fractures. DESIGN This was a retrospective, multicenter study. SETTING The study was conducted on an in- and outpatient basis. PATIENTS Patients included 287 adrenal incidentaloma patients (111 eugonadal males, 31 premenopausal, 145 postmenopausal females) and 194 controls (90 eugonadal males, 29 premenopausal, 75 postmenopausal females). MAIN OUTCOME MEASURE Bone mineral density (BMD) was measured by dual X-ray absorptiometry at lumbar spine and femoral neck. By radiograph each vertebra was assessed as intact (grade 0) or grade 1 (20-25%), 2 (25-40%), or 3 (>40%) deformity; SDI was calculated by summing the grade of deformity for each vertebra. SH was diagnosed in the presence of at least two of the following: urinary free cortisol greater than 70 microg per 24 h (193.1 nmol/liter), cortisol after 1-mg dexamethasone test greater than 3.0 microg/dl (>82.8 nmol/liter), ACTH less than 10 pg/ml (<2.2 pmol/liter). RESULTS BMD was significantly lower in SH+ than SH- patients and controls (lumbar spine -0.73 +/- 1.43, 0.17 +/- 1.33, 0.12 +/- 1.21, respectively; femoral neck -0.37 +/- 1.06, 0.07 +/- 1.09, 0.17 +/- 1.02). Patients with SH had higher fracture prevalence and SDI than those without SH and controls (70.6, 22.2, 21.8%, respectively, P < 0.0001; 0.31 +/- 0.68, 0.39 +/- 0.93, 1.35 +/- 1.27, respectively, P < 0.0001). Fractures and SDI were associated with SH (odds ratio 7.27, 95% confidence interval 3.94-13.41, P = 0.0001; beta = 0.352, t = 6.241, P = 0.0001, respectively) regardless of age, BMD, menopause, and gender. CONCLUSION SH is associated with low BMD, high fracture prevalence, and reduced bone quality as measured by SDI.

Use of cabergoline in the long-term treatment of hyperprolactinemic and acromegalic patients.

Cabergoline (Cab), a very potent and long-lasting dopaminergic compound, was administered to 26 women with pituitary microprolactinoma [mean serum PRL levels: 124.8±11.3 µg/l (±SE), range 62–300 µg/l] and 3 patients with GH-secreting pituitary adenoma (2 with associated PRL hypersecretion) for 12 and 24 months, respectively. In microprolactinomas, a stable normoprolactinemia was achieved in 96.1% of cases: in 13 women (50%) with the lowest dose of the drug (0.5 mg/week), and in other 12 patients (46.1%) with increasing doses up to 3 mg/week. All the oligomenorrheic/amenorrheic women, except one, restored regular and ovulatory menses. Two patients became pregnant. Pituitary abnormalities at high resolution-CT (HR-CT) scan disappeared in 13 of 19 patients (68.4%) after 12 months of therapy and this feature persisted in 8/13 cases (61.5%) 12 months after drug withdrawal. During Cab discontinuation (range: 3–60 months), mean serum PRL levels remained significantly lower than the basal ones. Six of 25 women are still without therapy. In 2 patients, normoprolactinemia persisted up to 38 and 60 months, respectively. Cab treatment was re-instituted in 13 patients because of the recurrence of hyperprolactinemia. Five patients were lost at follow up. In all the acromegalic patients, Cab (1–3 mg/week) normalized serum GH, IGF-I and PRL levels. A clear improvement in clinical symptoms was observed in all patients, but neuroradiological improvement in only one. Cab therapy was very well tolerated, as only seven patients complained of mild and transient side-effects and none had to stop treatment. In conclusion, Cab is an effective, safe, and well tolerated dopaminergic compound for the treatment of hyperprolactinemic disorders and the control of the clinical and hormonal features of dopamine-sensitive acromegalic patients.

Prevalence of thyroid diseases in patients with acromegaly: results of an Italian Multi-center Study

Acromegaly is frequently associated with the presence of thyroid disorders, however the exact prevalence is still controversial. An Italian multicenter study was performed on 258 patients with active acromegaly (high levels of IGF-I and lack of suppression of serum GH levels below 2 μg/l after an OGTT). The control group was represented by 150 patients affected by non-functioning and PRL-secreting pituitary adenomas. Two hundred and two out of 258 acromegalic patients (78%) were affected by thyroid disorders with a significantly higher prevalence with respect to the control group (27%, p<0.0001). One hundred and three patients presented (39.9%) non-toxic nodular goiter, 46 (17.8%) non-toxic diffuse goiter, 37 (14.3%) toxic nodular goiter, 1 toxic diffuse goiter (0.4%), 12 (4.6%) Hashimoto’s thyroiditis, 3 (1.2%) thyroid cancer. Two patients presented a co-secreting TSH pituitary adenoma. Thirty-six patients had been previously treated for various thyroid abnormalities. Among the 222 acromegalic patients never treated for thyroid disorders thyroid ultrasonography was performed on 194 subjects. Thyroid volume in patients with thyroid abnormalities was 28±17.5 ml (median 23) while it was 10.8±3.6 ml (median 10) in patients without thyroid disorders (p<0.0001). Thyroid volume was correlated with the estimated duration of acromegaly (r=0.7, p<000.1), but not with age or with serum GH, IGF-I and TSH concentrations. Thyroid volume was higher in acromegalic patients than in the above control population (23.5±16.9 ml vs 13.9±12.8 ml, p<0.0001). In 62 acromegalic patients 101 fine-needle biopsies of thyroid nodules were performed; 7 nodules were suspicious and the patients were submitted to thyroid surgery: papillary thyroid carcinoma was found in 3 patients. In conclusion, in a large series of acromegalic patients an increased prevalence of thyroid disorders (78%), particularly non-toxic nodular goiter, has been observed. Thyroid volume, evaluated by ultrasonography, was correlated to the estimated duration of acromegaly. Finally, the prevalence of thyroid carcinoma was slightly increased than in the general population.

Long-term follow-up in adrenal incidentalomas: an Italian multicenter study

CONTEXT The long-term consequences of subclinical hypercortisolism (SH) in patients with adrenal incidentalomas (AIs) are unknown. SETTING AND PATIENTS In this retrospective multicentric study, 206 AI patients with a ≥5-year follow-up (median, 72.3 mo; range, 60-186 mo) were enrolled. INTERVENTION AND MAIN OUTCOME MEASURES Adrenocortical function, adenoma size, metabolic changes, and incident cardiovascular events (CVEs) were assessed. We diagnosed SH in 11.6% of patients in the presence of cortisol after a 1 mg-dexamethasone suppression test >5 μg/dL (138 nmol/L) or at least two of the following: low ACTH, increased urinary free cortisol, and 1 mg-dexamethasone suppression test >3 μg/dL (83 nmol/L). RESULTS At baseline, age and the prevalence of CVEs and type 2 diabetes mellitus were higher in patients with SH than in patients without SH (62.2 ± 11 y vs 58.5 ± 10 y; 20.5 vs 6%; and 33.3 vs 16.8%, respectively; P < .05). SH and type 2 diabetes mellitus were associated with prevalent CVEs (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.1-9.0; and OR, 2.0; 95% CI, 1.2-3.3, respectively), regardless of age. At the end of the follow-up, SH was diagnosed in 15 patients who were without SH at baseline. An adenoma size >2.4 cm was associated with the risk of developing SH (sensitivity, 73.3%; specificity, 60.5%; P = .014). Weight, glycemic, lipidic, and blood pressure control worsened in 26, 25, 13, and 34% of patients, respectively. A new CVE occurred in 22 patients. SH was associated with the worsening of at least two metabolic parameters (OR, 3.32; 95% CI, 1.6-6.9) and with incident CVEs (OR, 2.7; 95% CI, 1.0-7.1), regardless of age and follow-up. CONCLUSION SH is associated with the risk of incident CVEs. Besides the clinical follow-up, in patients with an AI >2.4 cm, a long-term biochemical follow-up is also required because of the risk of SH development.

Predictors of morbidity and mortality in acromegaly: an Italian survey

OBJECTIVE To describe demographic and hormonal characteristics, comorbidities (diabetes mellitus and hypertension), therapeutic procedures and their effectiveness, as well as predictors of morbidity and mortality in a nationwide survey of Italian acromegalic patients. DESIGN Retrospective multicenter epidemiological study endorsed by the Italian Society of Endocrinology and performed in 24 tertiary referral Italian centers. The mean follow-up time was 120 months. RESULTS A total of 1512 patients, 41% male, mean age: 45±13 years, mean GH: 31±37 μg/l, IGF1: 744±318 ng/ml, were included. Diabetes mellitus was reported in 16% of cases and hypertension in 33%. Older age and higher IGF1 levels at diagnosis were significant predictors of diabetes and hypertension. At the last follow-up, 65% of patients had a controlled disease, of whom 55% were off medical therapy. Observed deaths were 61, with a standardized mortality ratio of 1.13 95% (confidence interval (CI): 0.87-1.46). Mortality was significantly higher in the patients with persistently active disease (1.93; 95% CI: 1.34-2.70). Main causes of death were vascular diseases and malignancies with similar prevalence. A multivariate analysis showed that older age, higher GH at the last follow-up, higher IGF1 levels at diagnosis, malignancy, and radiotherapy were independent predictors of mortality. CONCLUSIONS Pretreatment IGF1 levels are important predictors of morbidity and mortality in acromegaly. The full hormonal control of the disease, nowadays reached in the majority of patients with modern management, reduces greatly the disease-related mortality.

Risk of new vertebral fractures in patients with adrenal incidentaloma with and without subclinical hypercortisolism: a multicenter longitudinal study

In patients with adrenal incidentalomas (AIs), cross‐sectional studies suggested the presence of an association between subclinical hypercortisolism (SH) and an increased prevalence of vertebral fractures (VFx) and spinal deformity index (SDI), which is a clinical index of bone quality. No longitudinal studies investigated the incidence of VFx and SDI changes over time in SH. The aim of this study was to evaluate VFx risk and SDI changes in SH over time. One‐hundred‐three consecutive AI patients were studied at baseline and after 12 and 24 months. Patients were divided into SH+ (n = 27) and SH– (n = 76) groups on the basis of the presence of two or more among urinary free cortisol greater than 70 µg/24 hours, serum cortisol after 1‐mg dexamethasone suppression test greater than 3.0 µg/dL, and adrenocorticotropic hormone (ACTH) less than 10 pg/mL in 2 or more of the 3 evaluations. At baseline and after 24 months, bone mineral density (BMD) by dual‐energy X‐ray absorptiometry and the presence of VFx and SDI by summing the grade of deformity for each vertebra were evaluated. At the end of follow‐up, the SH+ group showed a higher prevalence of VFx (81.5%) as compared with baseline (55.6%, p = .04) and a worsening of SDI (2.11 ± 1.85 versus 1.11 ± 1.47, p = .032) associated with SH regardless of age, gender, body mass index , BMD, baseline SDI, menopause duration [odds ratio (OR) = 12.3, 95% confidence interval (CI) 4.1–36.5, p = .001]. The incidence of new vertebral fractures was higher in the SH+ group (48%) than in the SH– group (13%; p = .001). It is concluded that subclinical hypercortisolism is associated with an increased risk of VFx and a possible deterioration of bone quality.

Subclinical hypercortisolism: correlation between biochemical diagnostic criteria and clinical aspects.

Objective  Subclinical hypercortisolism (SH) has been associated with increased prevalence of hypertension, type 2 diabetes mellitus, dyslipidaemia, central obesity, osteoporosis and vertebral fractures. We aimed to investigate the accuracy of different SH diagnostic criteria in predicting the presence of complications.