Vincenzo Carnevale

Short and Long-Term Variations in Serum Calciotropic Hormones after a Single Very Large Dose of Ergocalciferol (Vitamin D2) or Cholecalciferol (Vitamin D3) in the Elderly

CONTEXT In humans, few studies have compared the potencies of ergocalciferol and cholecalciferol in improving and maintaining vitamin D status. OBJECTIVE Our objective was to evaluate the effects of a single very large dose of both calciferols on serum changes of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)(2)D], ionized calcium, and parathyroid hormone (PTH) at baseline, and at 3, 7, 30, and 60 d. DESIGN This was a prospective randomized intervention study. SETTING The study was performed in a nursing home residence. PARTICIPANTS A total of 32 elderly female patients (age range 66-97 yr), with vitamin D deficiency was included in the study. INTERVENTION Participants were randomized into four groups of eight to receive a single dose of 300,000 IU ergocalciferol or cholecalciferol by oral (os) or im route. RESULTS 25(OH)D levels sharply increased at d 3 only when vitamins were given os. The 30-d basal difference in serum 25(OH)D was significantly greater after cholecalciferol os administration (47.8 +/- 7.3 ng/ml) compared with other forms (D(3) im: 15.9 +/- 11.3; D(2) os: 17.3 +/- 4.7; D(2) im: 5 +/- 4.4; all P < 0.001). The area under the curve (AUC) of the serum 25(OH)D against time (AUC(60)) was: D(3) os, 3193 +/- 759 ng x d/ml vs. D(2) os, 1820 +/- 512, P < 0.001; and D(3) im, 1361 +/- 492 vs. D(2) im, 728 +/- 195, P < 0.01. 25(OH)D significantly influences PTH levels at 3 (P < 0.03), 7 (P < 0.01), 30 (P < 0.01), and 60 d (P < 0.05). At 60 d, the form of vitamin (cholecalciferol) significantly lowers PTH levels (P = 0.037). CONCLUSIONS Cholecalciferol is almost twice as potent as ergocalciferol in increasing serum 25(OH)D, when administered either by mouth or im. 25(OH)D plays a role in modulating serum PTH.

Longitudinal Evaluation of Vitamin D Status in Healthy Subjects from Southern Italy: Seasonal and Gender Differences

Abstract: Vitamin D status is currently considered among the relevant determinants of skeletal integrity. Since vitamin D levels present seasonal variations, we longitudinally studied young healthy men and women in order to investigate the related physiologic modifications of both calcium homeostasis and bone remodeling. Thirty-two men (mean age 39.4 ± 7.8 years) and 58 premenopausal women (aged 36.9 ± 6.4 years) from southern Italy were studied. In all subjects the following parameters were measured both in winter and in summer: serum calcium, phosphorus, creatinine, total alkaline phosphatase activity, 25-hydroxyvitamin D (25OHD), parathyroid hormone (PTH), osteocalcin (BGP), together with urinary calcium (Ca/Cr), total pyridinoline (Pyr/Cr) and deoxypyridinoline (d-Pyr/Cr), corrected for creatinine excretion. In both sexes 25OHD levels were significantly higher in summer, while PTH values were lower, than in winter. The prevalence of hypovitaminosis D, defined by concentrations of 25OHD lower than 30 nmol/l, was 17.8% in winter and 2.2% in summer in the whole sample, while it was 27.8% and 3.4%, respectively, among female subjects. Indeed male subjects did not display hypovitaminosis D, having throughout the year significantly higher calcium and 25OHD levels together with lower PTH values, than the women. Moreover, alkaline phosphatase total activity was more elevated in men both in winter and in summer. In women, during winter, bone remodeling markers levels were higher while urinary calcium levels were lower than in summer. In the whole sample serum 25OHD correlated positively with serum calcium and inversely with PTH. The seasonal percentage variations in PTH were inversely correlated with those of Ca/Cr. Our results show a relatively high prevalence of subclinical vitamin D deficiency among young healthy women from southern Italy. Significant gender-specific differences have been demonstrated in both calcium homeostasis and skeletal remodeling indexes; the seasonal fluctuations in the vitamin D–PTH axis are accompanied by cyclical variations of bone turnover rate, which were more pronounced in women.

Skeletal involvement in patients with diabetes mellitus

Studies on skeletal involvement in patients with diabetes mellitus have generated conflicting results, largely because of the pathogenetic complexity of the condition.

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

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.

Quality of life in ambulatory postmenopausal women: the impact of reduced bone mineral density and subclinical vertebral fractures

Health-related quality of life (HRQOL) in postmenopausal women with osteoporosis has hitherto been mainly assessed in patients with clinically recognized vertebral fractures. Our study aimed to investigate the QOL perception in 361 asymptomatic ambulant postmenopausal women who came to our center for an osteoporosis screening program planned with their general practitioners. The Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) was administered to all subjects. The participants underwent bone mineral density (BMD) measurements by DXA of either the lumbar spine and/or the femoral neck, as well as X-ray examination of the thoracolumbar spine to identify subclinical vertebral fractures. According to the WHO definition, where subjects are subdivided by BMD values into three groups (women with normal BMD, osteopenia, and osteoporosis), a significant difference was found only for the domains which explore general health perception (p<0.01 by ANOVA) and mental function (p<0.001 by ANOVA). When we segregated both osteopenic and osteoporotic women according to whether or not they had vertebral fractures, a significant difference was found only in osteoporotic patients for domains which explore physical function (p<0.001), social function (p<0.001), general health perception (p<0.02), and total QUALEFFO score (p<0.01). Stepwise multiple logistic regression analysis of the whole sample showed that both vertebral fractures and a low femoral BMD impairs QOL perception, while age did not exert a significant influence. ROC curves analysis demonstrated a low discriminating capacity of individual domains and total QUALEFFO score for both vertebral deformities and BMD categorization. Our results showed that QUALEFFO is not able to discriminate between patients with or without subclinical vertebral fractures. However, some aspects of QOL appear to be impaired in patients with subclinical vertebral fractures or reduced BMD.

Effect of a single oral dose of 600,000 IU of cholecalciferol on serum calciotropic hormones in young subjects with vitamin D deficiency: a prospective intervention study.

CONTEXT Effects of vitamin D repletion in young people with low vitamin D status have not been investigated so far. OBJECTIVE We evaluated the effect of a single massive dose of cholecalciferol on calcium metabolism at 3, 15, and 30 d, compared to baseline. DESIGN AND SETTING We conducted a prospective intervention study in an ambulatory care setting. PARTICIPANTS Forty-eight young subjects with vitamin D deficiency participated in the study. INTERVENTION A single oral dose of 600,000 IU of cholecalciferol was administered to each subject. MAIN OUTCOME MEASURES We evaluated serum changes of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D, calcium, and PTH induced by a single load of cholecalciferol. RESULTS The 25(OH)D level was 15.8 ± 6.5 ng/ml at baseline and became 77.2 ± 30.5 ng/ml at 3 d (P < 0.001) and 62.4 ± 26.1 ng/ml at 30 d (P < 0.001). PTH levels concomitantly decreased from 53.0 ± 20.1 to 38.6 ± 17.2 pg/ml at 3 d and to 43.4 ± 14.0 pg/ml at 30 d (P < 0.001 for both). The trends were maintained in a subgroup followed up to 90 d (P < 0.001). Mean serum Ca and P significantly increased compared to baseline, whereas serum Mg decreased at 3 d. 1,25-Dihydroxyvitamin D significantly increased from 46.8 ± 18.9 to 97.8 ± 38.3 pg/ml at 3 d (P < 0.001) and to 59.5 ± 27.3 pg/ml at 60 d (P < 0.05). CONCLUSIONS A single oral dose of 600,000 IU of cholecalciferol rapidly enhances 25(OH)D and reduces PTH in young people with vitamin D deficiency.

Skeletal involvement in adult patients with endogenous hypercortisolism

Overt endogenous glucocorticoid excess is a well-recognized cause of bone loss and osteoporotic fractures. Cortisol excess inhibits bone formation, increases bone resorption, impairs calcium absorption from the gut, and affects the secretion of several hormones (in particular gonadotropins and GH), cytokines, and growth factors, influencing bone metabolism. The glucocorticoid excess mainly affects trabecular bone, leading to vertebral fractures in up to 70% of patients. Osteoporotic fractures may be the presenting symptom of an otherwise silent glucocorticoid excess and can precede the diagnosis of hypercortisolism by up to 2 yr. The removal of glucocorticoid excess leads to a recovery of bone mass which is, however, often incomplete and delayed, although it reduces the risk of osteoporotic fractures. Bisphosphonate therapy has been suggested to be useful in maintaining bone mass in these patients. Subclinical hypercortisolism, a condition of impaired hypothalamic-adrenal-axis homeostasis without the classical signs and symptoms of glucocorticoid excess, is a recently defined entity, which has been shown to be associated to increased bone resorption, bone loss, and high prevalence of vertebral fractures regardless of gonadal status. However, data about the effect of this subtle glucocorticoid excess on bone are still scarce and conflicting. Moreover, it is not yet known whether removing the cause of subclinical hypercortisolism leads to a recovery of bone mass and reduces the risk of osteoporotic fractures. Finally, recent data suggest that subclinical hypercortisolism is a common and underrated finding in patients with established osteoporosis. In summary, it is crucial to evaluate the risk of osteoporosis and fractures in patients with glucocorticoid excess; on the other hand, it also seems advisable to screen for glucocorticoid excess patients with osteoporotic fractures without known secondary causes of osteoporosis.

Skeletal turnover, bone mineral density, and fractures in male chronic abusers of alcohol

Background: Chronic alcohol abuse is a risk factor for osteoporosis and fractures, whose pathogenesis is still unclear. We investigated the influence of alcoholism and other risk factors on calcium and skeletal metabolism, bone mineral density (BMD), and fractures. Materials and methods: In 51 chronic male alcoholics without liver failure and 31 healthy controls, serum total and ionised calcium, phosphate, creatinine, 25-hydroxy vitamin D (25OHD), PTH, total (ALP) and bone-specific (BALP) alkaline phosphatase, osteocalcin (BGP), carboxy-terminal telopeptide of type I collagen (β-CTx), osteoprotegerin (OPG) and receptor activator of nuclear factor kappa B ligand (RANKL) were assessed. In patients only, we also measured serum testosterone, 17-β estradiol, LH, and IGF-I. BMD was measured by dual energy x-ray absorptiometry at lumbar spine (LS-) and femur [neck (FN-) and total hip (TF-)]. Vertebral fractures were identified by a semiquantitative method on thoraco-lumbar spine x-ray, non-vertebral fractures (as life-style factors) by history. Results: Alcoholics were leaner, had significantly higher ALP and BALP, and lower BGP and 25OHD levels than controls. No significant difference in other calcium and bone metabolism parameters was found. OPG/RANKL ratio was significantly higher in alcoholics. Beta-CTx negatively correlated with abuse duration. OPG positively correlated with daily alcohol assumption and with indexes of liver cytolysis. Though LS-, FN-and TF-BMD of alcoholics and controls did not significantly differ, patients had a much higher prevalence of vertebral fractures. The same was found considering both vertebral and non-vertebral fractures. Conclusions: Ethanol-induced skeletal damage seems mainly dependent on negative effects on bone formation. Lifestyle factors and traumas likely contribute to the high fracture incidence of alcohol abusers, independently of BMD.

Bone mineral density in acromegaly: the effect of gender, disease activity and gonadal status

objective Data on bone mineral density (BMD) in acromegaly are conflicting as most previous studies collectively evaluated eugonadal and hypogonadal patients of both sexes, with or without active disease. We have evaluated BMD in 152 acromegalic patients of both sexes with varying disease activity and gonadal status.