Y. Rhee

Oral bisphosphonate-related osteonecrosis of the jaw: the first report in Asia

SummaryBisphosphonate-related osteonecrosis of the jaw (BRONJ) is a serious side effect of bisphosphonate therapy. The incidence of BRONJ is known to be low among patients treated with oral bisphosphonates. We investigated the prevalence, demographics, clinical manifestations, and treatment outcome of 24 patients with oral BRONJ in Asian populations.IntroductionThe long-term safety of oral bisphosphonates is clinically important considering the rare but potentially serious complications such as bisphosphonate-related osteonecrosis of the jaw (BRONJ) versus the effect of reducing and preventing osteoporotic fracture. The incidence of BRONJ is known to be low among patients treated with oral bisphosphonates around the world. However, the prevalence in those taking oral bisphosphonates for osteoporosis in Asian populations is unknown. Moreover, a recent article, showing that the majority of reported patients who received alendronate were Asian American, raised concern about the prevalence of oral BRONJ in Asian populations. The objective of this study was to investigate the estimated prevalence, clinical characteristics, and treatment outcome of oral BRONJ in Asian populations.MethodsFrom October 2005 to December 2008, a retrospective review of medical charts identified 24 patients receiving oral bisphosphonates diagnosed as BRONJ at the Department of Oral and Maxillofacial Surgery, Yonsei University Dental Hospital, Seoul, South Korea.ResultsThe estimated prevalence of oral BRONJ was 0.05–0.07%. The average oral bisphosphonate treatment duration was 43.1xa0months (range, 5–120xa0months). Treatment with oral antibiotics and/or surgery including sequestrectomy or alveolectomy showed relatively favorable results.ConclusionsThe prevalence of oral BRONJ in Korea is similar to that reported previously in Western populations. We suggest that recognition of BRONJ and appropriate management pre- and post-dental surgery might reduce the frequency of BRONJ among patients receiving oral bisphosphonates.

Analysis of adrenal masses by 18F-FDG positron emission tomography scanning

This study aimed to analyse the characteristics of adrenal masses visible in the computerised tomography (CT) scans which have been also evaluated by 2‐[18F]fluoro‐2‐deoxy‐D‐glucose positron emission tomography (18F‐FDG PET), and to characterise the features of 18F‐FDG PET scans associated with various adrenal endocrine tumours, especially benign functional tumours. 18F‐FDG PET scans of 105 patients with adrenal masses on the CT scan were analysed. Positive uptakes in the 18F‐FDG PET scans were seen in 60 malignant tumours (54 metastasic lesions, six primary adrenal cancers) and seven benign tumours. The positive predictive value of 18F‐FDG PET imaging to characterise an adrenal mass as a malignant tumour was 90%; the corresponding negative predictive value to rule out malignancy was also 90%. Benign adrenal tumours were smaller than that of malignant lesions (pu2003<u20030.05). The mean standardised uptake value max (SUVmax) of the metastatic lesions [8.4u2003±u20036.5u2003(μCi/g)/μCi/kg] was significantly higher than that of the benign adrenal tumours [2.4u2003±u20031.2u2003(μCi/g)/μCi/kg, pu2003<u20030.001]. Examination of only the primary adrenal lesions revealed that all adrenocortical carcinomas, two of three cases of pheochromocytomas, three of five neuroblastomas and two of four cases of primary aldosteronism showed positive 18F‐FDG uptake. In conclusion, for patients presenting adrenal masses with a high probability of malignancy, 18F‐FDG PET can be used to differentiate malignant from benign adrenal lesions. However, the 18F‐FDG PET uptake did not show an always consistent pattern for endocrine tumours, which was probably due to the variability inherent in 18F‐FDG uptake. This study suggests that 18F‐FDG PET scanning can offer supporting data to localise and characterise adrenal tumours.

Osteonecrosis of the jaw induced by oral administration of bisphosphonates in Asian population: five cases

SummaryBisphosphonate-related osteonecrosis of the jaw (BRONJ) can occur irrespective of race. Old age and long-term use of corticosteroid may be a more reliable risk factor than racial characteristics.IntroductionBRONJ is an increasingly common problem. Most BRONJ occurs following an intravenous administration of bisphosphonate treatment for malignant bone disease and metastatic cancer. As the incidence of BRONJ caused by oral administration of bisphosphonate is quite low, it is believed that this medication is relatively safe and effective in preventing complications of osteoporosis, such as hip or spine fractures. The many known risk factors for BRONJ can be classified as drug-related, local, demographic, and systemic. One demographic and systemic risk factor is race. Most of the case reports of BRONJ present elderly, white women.MethodsIn this report, we describe five cases of BRONJ caused by oral administration of bisphosphonate in Asian population.ResultsAll the patients were female and over 65xa0years old. Three patients had been prescribed with corticosteroids for rheumatoid arthritis.ConclusionIrrespective of race, elderly women undergoing steroid therapy have an increased incidence of BRONJ even with oral administration of bisphosphonate.

Distinctive role of 6-month teriparatide treatment on intractable bisphosphonate-related osteonecrosis of the jaw

SummaryThe administration of teriparatide (TPTD) in conjunction with periodontal care could provide faster and more favorable clinical outcomes in previously refractory bisphosphonate-related osteonecrosis of the jaws (BRONJ) cases compared to conventional dental care, combination of surgery and antimicrobial treatment. We also found that underlying vitamin D levels might influence the response to TPTD treatment.IntroductionTreatment of BRONJ is quite challenging and there are no standard treatment modalities. In this retrospective, longitudinal study, we examined whether additional TPTD administration could be beneficial for the resolution of BRONJ lesions compared to conservative management, such as antimicrobial treatment with or without surgery, and also studied the factors influencing the response to TPTD.MethodsTwenty-four cases of intractable BRONJ were included: 15 subjects were assigned to the TPTD group and the other 9 subjects, who refused TPTD administration, were assigned to the non-TPTD group. All subjects in both groups continued calcium and vitamin D supplementation and the TPTD group additionally received a daily subcutaneous injection of 20xa0μg TPTD for 6xa0months.ResultsWhile 60.0xa0% of the non-TPTD group showed one stage of improvement in BRONJ, 40.0xa0% of the group did not show any improvement in disease status. In the TPTD group, 62.5xa0% of the treated subjects showed one stage of improvement and the other 37.5xa0% demonstrated a marked improvement, including two stages of improvement or complete healing, and there was not a single case that did not improve. The clinical improvement of BRONJ was statistically better in the TPTD group after the 6-month treatment (pu2009<u20090.05). Moreover, patients with higher baseline serum 25(OH)D levels showed better clinical therapeutic outcomes with TPTD.ConclusionsWe observed the beneficial effects of TPTD on BRONJ, and subjects with optimal serum vitamin D concentrations seemed to reap the maximum therapeutic effects of TPTD. A prospective, randomized, controlled trial should be needed to further evaluate the therapeutic efficacy of TPTD in the resolution of BRONJ.

Serum parathyroid hormone is associated with carotid intima-media thickness in postmenopausal women

Objectives:u2002 To test whether parathyroid hormone (PTH) might be related to the development of atherosclerosis in postmenopausal women, we measured serum levels of PTH, the carotid intima‐media thickness (IMT), and other clinical and biochemical parameters.

Differences in femoral neck geometry associated with age and ethnicity

SummaryWe studied femoral geometry in relation to age and ethnicity in a cross-sectional study. Age-associated cortical thinning showed the most pronounced effect, and Koreans studied here had thicker cortices and lower buckling ratios than those reported for other races. Cortical thickness may thus be a major determinant of hip fracture risk.IntroductionThe rate of hip fracture varies by age and ethnicity. The geometric properties of the femur influence femoral strength and fragility, but differences in femoral geometry according to age and ethnicity are poorly understood. To explain the high prevalence of hip fractures in the elderly and the relatively low hip fracture rate in Asian populations, we studied age-related changes and ethnic differences in femoral geometry.MethodsWe recruited 214 peri- or postmenopausal women aged 46 to 85xa0years (mean age, 60.6xa0years). Their proximal femoral bone mineral densities (BMD) were measured by quantitative computed tomography and further analyzed geometric properties.ResultsWe observed large declines in trabecular volumetric bone mineral density associated with aging (33.03% less than the reference value in the oldest group, respectively). Cortical thickness decreased remarkably with age as well, and only 53.94% of the baseline value remained in the oldest group. As a result, the cortical buckling ratio increased geometrically and reached 239.14% of the reference value in the oldest group. In comparisons with other ethnic groups, Korean subjects had thicker cortices than their American, European, and African counterparts.ConclusionsIn this cross-sectional study, cortical thickness showed a pronounced age-associated decrease, and the cortical buckling ratio showed a strong age-associated increase. This may in part explain the higher rates of hip fractures in the elderly. When compared with other races, Asians had thicker cortical bone and lower buckling ratios, which may partially explain the lower prevalence of hip fractures in Asians.

Early-stage chronic kidney disease, insulin resistance, and osteoporosis as risk factors of sarcopenia in aged population: The Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV), 2008–2009

SummarySarcopenia means the progressive loss of skeletal muscle mass and strength with aging. In this study, we found that insulin resistance, chronic kidney disease stage 3, and osteoporosis at the femur neck were closely associated with sarcopenia in elderly men. These conditions modified to slow down the progression of sarcopenia.IntroductionSarcopenia is known to have multiple contributing factors; however, its modifiable risk factors have not yet been determined. The aim of this study was to identify the most influential and modifiable risk factors for sarcopenia in elderly.MethodsThis was a population-based, cross-sectional study using data from the Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV), 2008–2009. This study included 940 men and 1,324 women aged 65xa0years and older who completed a body composition analysis using dual-energy X-ray absorptiometry. Sarcopenia was defined as an appendicular skeletal muscle mass divided by height2 of less than 1xa0standard deviation below the sex-specific mean for a younger reference group.ResultsUsing univariate analysis, age, body mass index (BMI), homeostasis model assessment for insulin resistance (HOMA-IR), limitations in daily activities, regular exercise, high-risk drinking, family income, osteoporosis, daily energy, and protein intake were associated with sarcopenia in men; age, BMI, limitations in daily activities, regular exercise, occupation, osteoporosis at the total hip, and daily energy intake were associated with sarcopenia in women. In the multivariate logistic regression analysis, HOMA-IR ≥2.5 (odds ratio [OR] for sarcopenia, 2.27; 95xa0% confidence interval [CI], 1.21–4.25), chronic kidney disease stage 3 (OR, 3.13; 95xa0% CI, 1.14–8.61), and osteoporosis at the femur neck (OR, 6.83; 95xa0% CI, 1.08–43.41) were identified as risk factors for sarcopenia in men.ConclusionsInsulin resistance, chronic kidney disease, and osteoporosis at the femur neck should be modified to prevent the acceleration of skeletal muscle loss in elderly men.

Gender-specific pleiotropic bone-muscle relationship in the elderly from a nationwide survey (KNHANES IV)

SummaryThe aim of this study was to examine the gender-specific association between sarcopenia and bone geometry/metabolic parameters. Low muscle mass was associated with greater deterioration of bone than in deterioration of glucose or lipid profiles. This bone–muscle relationship was more prominent in men than in women.IntroductionThere are few studies that report on gender differences in the effects of low muscle mass on bone and metabolic parameters in elderly subjects. This study aimed to assess the gender-specific influence of muscle mass on bone and metabolic parameters.MethodsA total of 2,264 participants (940 men and 1,324 women) whose age ranged from 65 to 92xa0years were analyzed using data from The Fourth Korea National Health and Nutrition Examination Surveys (2008–2009). We measured bone mineral density (BMD) and appendicular muscle mass using the dual-energy X-ray absorptiometry and also measured metabolic profiles.ResultsThe age-related trend in bone and muscle coincided in men but not in women. Femoral neck (FN) and total hip (TH) BMD were highly correlated with muscle mass in both genders. However, in women, this correlation was not significant in the lumbar spine (LS). In addition, this positive correlation was stronger in the FN or TH than in the LS and was stronger in men than in women. Subjects with sarcopenia were at a higher risk for osteoporosis in the FN, TH, and LS in men, and in the TH and FN in women. The degree of association between muscle mass and metabolic profiles was relatively very weak.ConclusionBone–muscle relationship was more prominent in men than in women. The gender differences in bone–muscle relationship may be helpful for the development of gender-specific preventive strategies in the elderly, especially in men.

Analysis of 18F-fluorodeoxyglucose positron emission tomography findings in patients with pituitary lesions

Background/Aims Although magnetic resonance imaging (MRI) is a good visual modality for the evaluation of pituitary lesions, it has limited value in the diagnosis of mixed nodules and some cystic lesions. We evaluated the usefulness of 18F-fluorodeoxyglucose positron emission tomography (FDG PET) for patients with pituitary lesions. Methods 18F-FDG PET and MRI were performed simultaneously in 32 consecutive patients with pituitary lesions. The relationships between FDG uptake patterns in PET and MRI findings were analyzed. Results Of 24 patients with piuitary adenomas, 19 (79.2%) showed increased uptake of 18F-FDG in the pituitary gland on PET scans. All patients with pituitary macroadenomas showed increased 18F-FDG uptake on PET scans. Meanwhile, only five (50%) of the 10 patients with pituitary microadenomas showed positive PET scans. Interestingly, of two patients with no abnormal MRI findings, one showed increased 18F-FDG uptake on PET. For positive 18F-FDG uptake, maximum standardized uptake values (SUVmax) > 2.4 had 94.7% sensitivity and 100% specificity. In addition, SUVmax increased in proportion to the size of pituitary adenomas. Most cystic lesions did not show 18F-FDG uptake on PET scans. Conclusions About 80% of pituitary adenomas showed positivity on PET scans, and SUVmax was related to the size of the adenomas. PET may be used as an ancillary tool for detection and differentiation of pituitary lesions.

Associations between serum 25-hydroxyvitamin D and bone mineral density and proximal femur geometry in Koreans: the Korean National Health and Nutrition Examination Survey (KNHANES) 2008–2009

SummaryThe association between 25-hydroxyvitamin D (25(OH)D) levels and bone mineral density (BMD) and proximal femur bone geometry was examined in the Korean population. A positive relationship between skeletal health and 25(OH)D levels was observed. However, there were no significant differences in skeletal health between the groups with 25(OH)D level of 50–75xa0nmol/L and greater than 75xa0nmol/L.IntroductionVitamin D plays an important role in calcium and phosphate homeostasis and normal mineralization of bone. However, the optimal level of vitamin D for skeletal health has not been clearly established. We analyzed the associations between serum 25(OH)D and BMD and proximal femur bone geometry and determined the optimal 25(OH)D level.MethodsThis was a cross-sectional study of 10,062 participants (20–95xa0years, 4,455 men, 5,607 women) in the Fourth Korea National Health and Nutrition Examination Surveys (KNHANES IV) conducted from 2008 to 2009. Participants were divided into groups according to 25(OH)D level (<25, 25–50, 50–75, and ≥75xa0nmol/L). BMD and proximal femur geometric indices were measured.ResultsThe group with 25(OH)D levels of 50–75xa0nmol/L had greater bone density values, with the exception of the lumbar spine, and also had greater femur neck cortical thickness, cross-sectional area, and cross-sectional moment of inertia, as well as a lesser buckling ratio than the groups with 25(OH)D level of 25–50xa0nmol/L and less than 25xa0nmol/L. However, there were no significant differences in BMD and proximal femur geometry properties between the groups with 50–75xa0nmol/L and greater than 75xa0nmol/L of 25(OH)D.ConclusionThe skeletal outcomes, including BMD and proximal femur geometric indices observed in this study, suggest that serum 25(OH)D levels of 50 to <75xa0nmol/L are optimal for skeletal health.