P. Oriente

Determinants of bone mineral density in immobilization: A study on hemiplegic patients

Osteoporosis that develops during immobli-zation is a severe condition that confers increased risk of fractures with their burden of mortality and disability. The aim of this study was to investigate the determinants of immobilization osteoporosis. As a model of this condition we studied hemiplegic subjects, measuring bone mineral density in the paralyzed lower limb as compared with the non-paralyzed one. In spite of the limits related to the loss of nervous stimulation, this model offers the advantage of a proper control for the complex genetic and environmental cofactors involved. We examined 48 hemiplegic subjects (31 men, 17 women in menopause) admitted consecutively over a 9-month period. Mean length of immobilization was 10.9 months for men (range 1–48 months) and 7.8 months for women (range 1–40 months). The average time since menopause was 14.9 years (range 1.7–23.9 years). For each subject the following were performed: questionnaire, medical examination, anthropometric measurements, evaluation of the scores for spasticity and for lower limb motor capacity in order to account for the different degrees of disability among patients. Bone mineral density was measured using dual-energy X-ray absorptiometry (DXA) at both femoral necks. For each patient we defined a percentage difference in bone loss between the paralyzed and non-paralyzed limb. Regression coefficient were calculated by multiple logistic regression. There was significant bone loss in the paralyzed limb in both sexes, accounting for up to 6.3% in women. Multiple regression analysis showed that the degree of bone loss depends significantly and directly on the length of immobilization, even when controlling for age and sex in the regression model (R=0.193,p=0.034). However, when time since menopause was included in the regression model, with length of immobility as a covariate, it was the only significant determinant of bone loss (R=0.312,p=0.039). No additional factors were observed among men. No differences were shown with regard to anthropometric measurements or functional scores. Length of immobilization accounts only for a small fraction of bone loss, which does not exceed 5% of the total variance. Our data show that postmenopausal women should be considered at highest risk for osteoporosis in cases of immobility and that different factors, other than length of immobility, might come into play in determining bone loss in this condition.

Interplay between environmental factors, articular involvement, and HLA-B27 in patients with psoriatic arthritis.

Medical records of 138 patients with psoriatic arthritis and 138 with rheumatoid arthritis were reviewed for the occurrence of an environmental factor triggering arthritis. Twelve (9%) of the patients with psoriatic arthritis had had an acute disorder immediately preceding onset of arthritis (an operation in four cases, articular trauma in three, abortion in two, myocardial infarction, thrombophlebitis, and phosphoric ester intoxication in one case each). Peripheral arthritis occurred in all these patients. Among the rheumatoid patients, an acute event immediately preceding the onset of the disease was recorded in two cases (1%) only (chi 2 = 7.52; p = 0.006). No significant association was found in the arthritic patients between the incidence of acute events preceding arthritis onset and positivity of the HLA-B27 phenotype.

Bone mineral density in premenopausal women receiving levothyroxine suppressive therapy

Osteoporosis is a well-known complication of thyrotoxicosis. Prolonged subclinical hyperthyroidism due to L-thyroxine treatment has been associated with reduced bone mass and thus with the potential risk of premature development of osteoporosis. The aim of this study was to assess the effect of a chronic L-thyroxine suppressive treatment on bone mineral density (BMD) in a group of premenopausal women. Forty consecutive patients (mean age +/- SE = 40.95 +/- 1.56 years) affected by non-toxic goiter underwent bone mineral densitometry (dual energy X-ray absorptiometry; DEXA) of the lumbar spine (L1-L4) and right femoral neck. At the time of the study the patients had been under thyroid stimulating hormone (TSH) suppressive therapy for 74.95 +/- 10.34 months (range 17-168 months). Baseline levels of free thyroxine (fT4), free triiodothyronine (fT3), TSH, calcium and phosphorus were measured and correlated with BMD. The age of starting, duration of treatment, main daily dose, cumulative dose of treatment and body mass index (BMI) were also correlated with BMD. Statistical analysis was performed by multiple linear regression. BMD among female patients was not significantly different from that of the general population matched for age and sex. With the use of the regression model, no significant correlation was found between BMD and the variables considered. In conclusion, our data suggest that L-thyroxine suppressive therapy, if carefully carried out and monitored, has no significant effect on bone mass.

Bone mineral density and bone markers in hypogonadotropic and hypergonadotropic hypogonadal men after prolonged testosterone treatment.

After prolonged treatment (76.4±10 and 70.1±12.3 months, respectively) (mean± SE) with testosterone enanthate (250 mg im every 3 weeks), bone mineral density (BMD) and bone metabolism were evaluated in 12 patients (aged 29.3±1.4 yr) affected by idiopathic hypogonadotropic hypogonadism (IHH), in 8 patients (29.6±2.6 yr) affected by Klinefelter’s syndrome (KS), and in 10 healthy men (30.6±1.7 yr) matched according to age and BMI. Spinal BMD in IHH was significantly lower than in controls (0.804±0.04 vs 1.080±0.01 g/cm2; p<0.001), while there was no difference in neck BMD (0.850±0.01 vs 0.948±0.02 g/cm2). Neither spinal (0.978±0.05 g/cm2) nor neck (0.892±0.03 g/cm2) BMD in KS were significantly different from controls. Six IHH and one KS subjects were osteoporotic, while 6 IHH and 2 KS subjects were osteopenic. A significant inverse correlation was found between spinal BMD and age at the treatment onset in IHH (r=−0.726, p=0.007). In IHH there were significant increases in bone formation (alkaline phosphatase=318.3±33.9 vs 205.4±20.0 IU/l; osteocalcin=13.44±1.44 vs 8.57±0.94 ng/ml; p<0.05) and in bone resorption (urinary cross-linked N-telopeptides of type I collagen= 149.1± 32.3 vs 47.07±8.4 nmol bone collagen equivalents/mmol creatinine; p<0.05) compared to controls, while such differences were not present in KS. Our results outline the importance of BMD evaluation in all hypogonadal males. Nevertheless, bone loss is a minor characteristic of KS, while it is a distinctive feature of IHH. Therefore, early diagnosis and age-related replacement therapy coupled with a specific treatment for osteoporosis could be useful in preventing future severe bone loss and associated skeletal morbidity.

Is the involvement of the distal interphalangeal joint in psoriatic patients related to nail psoriasis

The aim of this study was to investigate the relationship between onychopathy and distal interphalangeal (DIP) joint involvement in psoriatic patients. Twenty-five consecutive unselected, unrelated patients with psoriatic onychopathy and 25 consecutive unselected, unrelated patients with psoriatic arthritis without onychopathy, were enrolled in the study. X-ray films of the hands were taken to identify DIP arthritic involvement and/or bone changes of the distal phalanx, which were categorized into five classes (0: no lesions; 1: tuftal minimal erosions; 2: tuftal bone resorption; 3: tuftal periosteal osteitis; 4: overlap of erosive and osteitic changes). Ten psoriatic patients with onychopathy and 8 without showed DIP arthritis, with no statistical differences in this distribution (p=0.556). Bone changes of the distal phalanx were found in all 25 psoriatic patients with onychopathy and in 18 without. The distribution of patients in different categories of involvement of the distal phalanx showed that patients without onychopathy were markedly distributed in the categories with no or minimal lesions, whereas patients with onychopathy had structural changes prevailing included in categories with more severe bone changes (osteitis and overlap of erosive and osteitic changes) (p=0.002). Onychopathic patients with DIP arthritis were older than those without (p<0.0001) and showed a longer duration of onychopathy (p<0.0001). Although the occurrence of DIP arthritis seems to depend on the duration of nail involvement, no statistical difference has been found in the distribution of DIP arthritis in psoriatic patients with or without onychopathy. In contrast, a topographical association between bone changes of the distal phalanx and dystrophy of the adjacent nail may be advanced.

Epidemiology of osteoporosis in women in southern Italy

Studies on the distribution of bone mineral density (BMD) values in different age groups and in different populations are valuable for understanding the causes of the appreciable geographical variability in fracture incidence. We studied a population of southern Italy in an area where the incidence of hip fracture had been previously estimated. With a completion rate of 85%, we recruited a group of 264 women between 45 and 79 years of age, representative of non-institutionalized and active women in the population, and measured bone density both at the lumbar spine (L1–L4) and at the right femoral neck using a dual X-ray absorptiometry (DEXA) system. We report the age group distribution of BMD in this population. The elderly showed higher mineralization, as compared to an international pooled sample. The prevalence of osteoporosis among women of 50–79 years of age was 40%; the rate changed according to the measurement site. Our results show that a large proportion of women would not have been diagnosed as having osteoporosis if we had relied on a single measurement site. A very low percentage of cases (as low as 4% in the 50–59 years age group) was diagnosed at both sites. The lack of concordance in BMD estimate between measurement sites is significant at younger ages, with an almost dichotomous distribution of cases diagnosed either at the lumbar or femoral site, suggesting the hypothesis that distinct patterns of bone involvement and bone mass lowering exist and all eventually lead to systemic involvement. Longitudinal follow-up of this population should help address some of the questions raised by these results.

Dietary calcium intake and serum vitamin D are major determinants of bone mass variations in women. A longitudinal study.

Background and aims: Bone mineral density (BMD) is one of the main determinants in the pathogenesis of fractures. However, data on factors predicting longitudinal variations in BMD are still limited and incomplete. Such data would be of great importance in order to better focus prevention strategies in both the clinical setting and at the population level. The aim of the study was to investigate the predictive value of both serological and questionnaire variables for bone mass variations in healthy women participating in a population-based longitudinal study carried out in Napoli, Italy. Methods: High completion rate (85.2%) and adequate sample size were obtained: 139 women (45 to 79 years of age) were examined at study entry and then again after two years (24±2 months) following the same protocol. They underwent medical examination, questionnaire, anthropometric measurements, blood sampling and urine collection. BMD was measured by dual energy X-ray absorptiometry (DEXA) at the lumbar spine (L1-L4) and femoral neck. Data analysis included calculation of the percent variation in BMD in the 2-year period. Longitudinal data underwent stepwise analysis for a global evaluation of mutual interactions between independent variables. Results and conclusions: Our findings indicate that dietary and serum calcium, and serum 25(OH)vitamin D are the only independent determinants of BMD variations at the lumbar and femoral level, respectively. While the pharmacological significance of calcium and vitamin D in the therapy of established osteoporosis is still controversial, the present longitudinal data evidence their role as essential nutrients in determining the natural history of BMD variations.

The classification of psoriatic arthritis: What will happen in the future?

Some patients with psoriasis have articular involvement that falls within the spectrum of seronegative spondyloarthropathies. This form of arthritis has been classified by Moll and Wright into five clinical subsets. Recently this classification has been contested. We review the historical evolution of the concept of psoriatic arthritis and discuss its clinical spectrum.

ACECLOFENAC VERSUS NAPROXEN IN THE TREATMENT OF ANKYLOSING SPONDYLITIS: A DOUBLE-BLIND, CONTROLLED STUDY

Abstract The efficacy and tolerability of aceclofenac and naproxen sodium in the treatment of ankylosing spondylitis (AS) were evaluated and compared in this double-blind, multicenter, controlled study. Of the 130 patients who entered the study, 126 patients met the inclusion criteria. Efficacy was evaluated at baseline, 15 days, and 1, 2, and 3 months using a visual analog scale for spontaneous pain, a zero to three-point scale for pain on movement and pain at rest, and measurements of chest expansion, hand-to-floor distance, Schobers test, and normal daily activities. No significant between-group differences were seen for any of the variables at baseline, except hand-to-floor distance. Both drugs provided effective analgesia and a corresponding improvement in functional activity. Overall efficacy assessment made by the physician and patients was not statistically significant between the two treatment groups. The overall incidence of adverse effects was higher in the naproxen group than the aceclofenac group, 22 versus 15 patients, respectively. All adverse effects resolved. However, the overall assessment of tolerability given by the physician and patients was significantly ( P

Diffuse idiopathic skeletal hyperostosis (DISH): a retrospective analysis.

SummaryDiffuse idiopathic skeletal hyperostosis (DISH) is a skeletal disease characterized by ligamentous ossification of the anterolateral side of the spine. The radiographs of the spine of 69 patients (22 males, 47 females, mean age 64.97±8.83 years) affected by DISH according to Resnicks criteria were selected. A lower rate of lumbar spine involvement (71%) and a different distribution between sexes were demonstrated, as compared to the data from the literature. Data on relationships among extent of hyperostosis, occupation and metabolic disorders suggest that an important role might be played by the exposure to microtrauma, while, in subjects affected by a metabolic disorder, this condition would represent a prevalent pathogenetic factor. These data underline some peculiarities in the clinical picture of DISH in the population from Campania, that could depend on genetic factors.