Use of quantitative ultrasound to assess bone status in children with juvenile idiopathic arthritis: a pilot study.

Periarticular osteoporosis around inflammed joints and generalized osteoporosis have been shown to be markers of disease activity and severity in children with juvenile idiopathic arthritis (JIA). Bone mineral density (BMD) in adults can be assessed precisely by dual X-ray absorptiometry (DXA), but this technique has not been used widely in children. Quantitative ultrasound (QUS) may provide an alternative method for assessment of bone status. The aim of this pilot study was to compare QUS to DXA in assessing generalized osteoporosis in a cohort of patients JIA. Twenty-two Caucasian children (15 females, 7 males) with JIA of duration 19-142 months (mean 71 mo) and age 7-17 yr were recruited. Total body and lumbar spine BMD and bone mineral content (BMC) were measured by DXA using standard procedures on a Lunar DPX-L scanner. QUS was performed using Myriad SoundScan 2000. Speed of sound (SOS) was measured at the right midtibia. The DXA results were compared to QUS using linear regression analysis. Spine and total body BMD measured by DXA correlated significantly with tibia SOS (spine: r = 0.57, p < 0.007; total body: r = 0.68, p < 0.001). Spine BMC was similarly related to SOS as BMD (r = 0.58, p < 0.007). Individual patient weight and height were strong predictors of BMD, but only moderate predictors of SOS. The mean spine BMD was lower in the JIA patients compared to the normal ranges (mean Z-score of -1.19). BMD Z-scores were negatively associated with disease duration. Patients taking steroids were associated with lower Z-scores. In conclusion, SOS shows a significant correlation with BMD as measured by DXA, albeit with wide 95% confidence intervals in this small pilot study. QUS was also well tolerated and was technically easy to perform in these children. With the added advantage that it is free from radiation risk, further assessment of this potentially valuable tool for measuring bone status in children is warranted.     

Distribution of Z-Scores in a University Cohort With an Emphasis on “High” Bone Mineral Density

High bone mineral density (BMD) is currently not defined by the International Society for Clinical Densitometry with a specific Z-score cutoff; however, it has been suggested that a Z-score greater than or equal to 2.5 is not normal. Institutional Review Board approval was obtained. We evaluated a University dual-energy X-ray absorptiometry database over the previous 24 mo to define Z-score distributions. A Z-score greater than or equal to 2.5 was selected as the outcome event of interest in a logistic regression for adjusted odds ratio. The covariates were height; weight; body mass index (BMI); gender; menopausal status; use of female hormones; presence of insufficiency fractures after 50 yr of age; previous fractures; previous surgeries (back surgeries, vertebroplasty, or kyphoplasty); transplant history; presence of long-term chronic conditions (asthma, lupus, rheumatoid arthritis, or cystic fibrosis); eating disorder; current use of glucocorticoids; smoking status; and current and past use of osteoporosis pharmacological therapies. The study included a total of 8216 patients; 7212 (87.8%) were females, and 1044 (12.2%) were males. In the total population, 13.6% had a Z-score greater than or equal to 2.5 at the lumbar spine, femoral neck, or total hip. Only 0.2% of the males and 0.8% of the females had a Z-score greater than or equal to 2.5 at all 3 sites. The 97.5th percentiles for Z-scores in our population for men and women, respectively, were 3.4 and 3.9 at the lumbar spine, 1.5 and 2.1 at the femoral neck, and 1.6 and 2.2 at the total hip. The 99th percentile for Z-scores for men and women, respectively, were 4.9 and 4.7 at the lumbar spine, 2.4 and 2.7 at the femoral neck, and 2.2 and 2.7 at the total hip. At the lumbar spine, female gender and weight were found to be risk factors for a high Z-score (≥2.5). The use of glucocorticoids, bone-active medications, BMI, and smoking were significantly less likely to predict a lumbar spine Z-score greater than or equal to 2.5. A high total-hip Z-score is predicted by increasing weight, whereas those patients using bone-active medications were less likely to have high BMD at the total hip. At the femoral neck, there were no significant risk factors related to a Z-score greater than or equal to 2.5; those taking bone-active medications were significantly less likely to have a high Z-score. These data suggest that a high Z-score is common at 1 or more sites. Further research about the criteria for the diagnosis of high BMD is warranted.     

Evaluation of the bone status in high-level cyclists

The purpose of this study was to evaluate the bone status in highly trained professional cyclists subjected to regular training and tough competitions. Bone mineral density (BMD) was measured at different regions of interest by dual-energy X-ray absorptiometry, and main biological parameters related to bone metabolism were obtained in 29 cyclists. Lumbar BMD was 0.94 ± 0.01g/cm(2) (Z-score=-1.28 ± 0.07), and 1 cyclist out of 4 had an abnormally low value (Z-score <-2). The mean Z-score at the total femoral site was -1.22 ± 0.21, and 45% of athletes had an Z-score of <-2. All femoral neck BMD values were within normal boundaries. The lowest BMD Z-score was measured at the midradius or 1/3 proximal site with a mean Z-score of -1.77 ± 0.78, but only 3 cyclists (15%) had Z-scores <-2. Biochemical parameters of bone formation (serum osteocalcin and alkaline phosphatase) were normal. Three cyclists had low 25-hydroxyvitamin D levels. Blood testosterone and thyroid stimulating hormone were in the normal range. Insulin-like growth factor 1 levels were in the normal range; however, a significant inverse correlation was found with lumbar BMD (r=0.495; p=0.003). We confirm that cycling has no positive effect on BMD, BMD being often lower than in normal controls at the lumbar site; femoral BMD is less concerned. The absence of beneficial changes at the spine can be explained by biomechanical conditions related to the cyclists' position, reducing loading strains. It is necessary to pay greater attention to the bone status of high-level athletes to prevent an increased risk of fractures.     

Uncoupling of Bone Turnover may Compromise Skeletal Health of Young Patients With Haemophilia A

There is evidence that bone mass is decreased and bone metabolism is dysregulated in children with haemophilia (CWH). The objective of this study was to investigate the impact of haemophilia on skeletal health in children, with regards to bone mineral density (BMD) and metabolic bone profile. This study included 51 male CWH A. Dual-energy X-ray absorptiometry (DXA) was performed to assess BMD in lumbar spine (LS) and total body less head (TBLH) and Z-scores were calculated (low BMD Z-score<-2, low-normal BMD Z-score between -1 and -2). Serum levels of osteocalcin (OC), procollagen type I C-terminal propeptide (PICP), bone alkaline phosphatase (bALP), bone tartrate-resistant acid phosphatase 5b (TRAP5b), vitamin D, parathormone (PTH), urinary calcium/creatinine (uCa/uCr) and urine deoxypyridinoline/creatinine (uDPD/uCr) were measured. Mean BMD Z-scores were lower than predicted at both sites of measurement. More specifically, 10% of CWH A had low and 20% low-normal BMD Z-scores in LS, whereas 9.1% had low-normal TBLH BMD Z-scores and there were no patients with low BMD Z-scores at this site of measurement. 36.7% of CWH had low vitamin D levels and 19.6% had a history of fracture. Also, patients with haemophilia had lower OC and higher uDPD/uCr levels while OC positively correlated to BMD Z-scores and uDPD/uCr negatively correlated to BMD Z-scores at both sites. No statistically significant differences were observed with regards to mode of treatment, number of haemorrhages and the presence of target-joints. CWH A had decreased BMD Z-scores at both sites with an uncoupling of bone turnover LS BMD seemed to be more affected than TBLH BMD.     

Negative correlation between bone mineral density and TSH receptor antibodies in male patients with untreated Graves’ disease

Introduction Although it has been established that hyperthyroidism leads to reduced bone mineral density (BMD), with accelerated bone turnover promoting bone resorption in female patients, there is a dearth of data for male patients with hyperthyroidism. This study evaluated BMD and bone metabolism in male patients with Graves’ disease. Methods The study included 56 Japanese male patients with newly diagnosed Graves’ disease and 34 normal Japanese male control subjects of similar age and body mass index. We used dual energy x-ray absorptiometry to measure BMD at sites with different cortical/cancellous bone ratios (lumbar spine, femoral neck, and distal radius). Results At the lumbar spine and the distal radius, BMD and T-scores were significantly lower for patients than for controls. At the femoral neck, on the other hand, the same values were relatively, but not significantly, lower in patients than in controls. However, Z-scores at all three sites were significantly lower for patients than for controls. The Z -score at the distal radius of patients was significantly lower than that at their lumbar spine and femoral neck. In addition, Z-score at the distal radius correlated negatively with age, free thyroxine, thyroid stimulating hormone receptor antibodies, thyroid stimulating antibody, and urinary N-terminal telopeptide of type I collagen normalized by creatinine. Conclusions These results indicate a high prevalence of cortical bone loss in male patients with Graves’ disease, especially elderly patients. We conclude that BMD measurement is crucial in all Graves’ disease patients regardless of their gender and that the radial BMD as well as BMD at the lumbar spine and femoral neck should be monitored to effectively prevent bone loss and subsequent fracture.     

Discordance in DXA male reference ranges.

Previous studies have reported discordance in female lumbar spine and proximal femur dual-energy X-ray absorptiometry (DXA) reference ranges. Although the NHANES III reference range is recommended for the proximal femur in males and females, there are no published data in men on the concordance or otherwise of the different manufacturer-specific lumbar spine bone mineral density (BMD) reference ranges. Potentially, the use of different reference populations by different manufacturers could result in inconsistencies in the diagnosis of osteopenia or osteoporosis. We compared lumbar spine BMD, as well as T-scores and Z-scores, in 45 men scanned using Lunar DPXL and Norland Excel densitometers. The BMD measured by the two instruments was highly correlated (lumbar spine: r = 0.99, p < 0.0001). However, the two instruments assigned significantly different BMD T-scores. These differences relate primarily to the different standard deviations employed in the calculations. There were also significant differences when BMD was expressed with respect to age-matched values (Z-scores). This study shows that in men, as previously demonstrated in women, two commonly used DXA instruments provide comparable lumbar spine standardized BMD, but there are significant differences in derived T-scores because of differences in the manufacturer-specific reference ranges. Standardization of lumbar spine reference ranges in men should be a high priority.     

Bone mass after long-term euthyroidism in former hyperthyroid women treated with (131)I influence of menopausal status.

The objective of this study was to assess bone mineral density (BMD) and bone markers in former hyperthyroid females after long-term euthyroidism (>4 yr) following (131)I therapy, as well as the potential influence of the timing of menopause. Twenty-six females ages 57 +/- 8 yr previously diagnosed with hyperthyroidism and treated with (131)I who were euthyroid for a minimum of the last 4 yr (10 +/- 5 yr) were studied. Eighteen patients (69%) were on levothyroxine (LT(4)) replacement therapy for 9 +/- 4 yr. BMD (g/cm(2) and Z-score) was measured by dual X-ray absorptiometry in the lumbar spine, femoral neck, and Ward's triangle. BMD (Z-score) was lower than the normal reference values for the Spanish population in all sites (lumbar spine: -0.65 +/- 1.13; femoral neck: -0.47 +/- 0.95; Ward's triangle: -0.37 +/- 0.88). No differences were found between BMD values according to the etiology of the hyperthyroidism or current LT(4) therapy. Current postmenopausal patients (n = 21) showed lower BMD than current premenopausal patients in the lumbar spine and femoral neck (p < 0.05). Those women who were postmenopausal at the time of the (131)I therapy (n = 15) also had lower lumbar spine BMD than premenopausal patients (p = 0.01), while no significant difference in BMD was seen according to the menopausal status when hyperthyroidism was diagnosed. Former hyperthyroid patients after long-term euthyroidism following (131)I therapy showed reduced BMD at the lumbar spine and proximal femur. Menopausal women showed a greater reduction in bone density. The menopausal status at the time of diagnosis did not seem to have long-term effects in bone density; nevertheless, an early therapeutic intervention in premenopause is suggested to reduce bone loss.     

Bone mineral density and bone histomorphometry in children on long-term dialysis

Bone mineral density (BMD) at the lumbar vertebrae (L(1)-L(4)) was assessed by dual-energy X-ray absorptiometry (DXA) in 20 children with chronic kidney disease (CKD) on dialysis, and its results were compared with bone biopsy and biochemical parameters. Biopsy specimens provided evidence of hyperparathyroid bone disease in eight cases (40%), and low bone turnover in 12 (60%). For BMD, expressed as Z-scores relative to normal, median Z-scores were -1.05 (range -2.36 to 1.06) for hyperparathyroid patients and -1.05 (range -4.40 to -0.03) for low bone turnover patients, with no statistical differences between groups (P = 0.512). In relation to BMD, of the whole sample, five (25%) had a Z-score under -2.0. When it was corrected for height, BMD was in the normal range. Additionally, there were no significant differences in single samples of serum calcium, alkaline phosphatase, phosphorus and intact parathyroid hormone (PTH) between groups with high or low bone turnover. Assessment of nutritional status, through height/age, showed that ten patients had Z-scores below -2.0 (median -2.12, range -7.13 to 0.73). In conclusion, renal osteodystrophy (ROD) seems to have a high prevalence among CKD pediatric patients, although only approximately a quarter of them developed changes in BMD. In children with CKD, measurements of bone mineral density may not be used for classification of various forms of ROD.     

Low lumbar spine bone mineral density in both male and female endurance runners

There have been many reports of low bone mineral density (BMD) in female endurance runners. Although there have been several reports of low BMD in male runners, it is unclear how comparable the problem is to that in females. We compared BMD between male and female endurance runners and with a reference population. One hundred and nine endurance runners (65 females, 44 males) aged 19-50 years participated and had been training regularly for at least 3 years (32-187.2 km week(-1)) in events from 3 km to the marathon. BMD was measured at the lumbar spine (L2-L4) and hip by DXA. A questionnaire assessed training and menstrual status. Lumbar spine T scores were similar in male and female runners (-0.8 (0.8) versus -0.8 (0.7); f = 0.015; P = 0.904) as were total hip T scores (0.6 (7.9) versus 0.5 (9.2); f = 0.192; P = 0.662). The proportion of male runners with low lumbar spine BMD (<-1.0) (n = 16 from 44) compared to that of females (n = 27 from 65) (P = 0.675). Males had lower spine T scores than eumenorrhoeic females (-0.8 (0.7) versus -0.4 (0.7); f = 5.169; P = 0.03). There were moderate negative correlations between weekly running distance and lumbar spine BMD in males and females (r(2) = 0.267; 0.189; P < 0.001), independent of menstrual status in females (r(2) = 0.192; P < 0.001). Lumbar spine but not hip T scores were greater in runners who participated in resistance training at least twice-a-week (male: -0.4 versus -1.1; female: -0.5 versus -1.1; P < 0.01). Using multiple regression, running distance (-) and BMI (+) together best predicted lumbar spine T scores (r(2) = 0.402; P < 0.01) in females. Although weak, BMI (+) best predicted hip T scores (r(2) = 0.167; P < 0.05). In males, running distance and training years (-) together best predicted lumbar spine T scores (r(2) = 0.400; P < 0.01). Training years (-) best predicted hip T scores (r(2) = 0.361; P < 0.01). To conclude, our findings suggest that male runners face the same bone threat at the spine, as female runners. Further research in male athletes is required. Incorporation of regular resistance training into an athlete's training programme may be a useful preventative strategy.     

Vertebral Fracture Assessment in Adolescents and Young Women With Anorexia Nervosa: A Case Series

Rates of vertebral fracture (VF) in young women with anorexia nervosa (AN) are not well understood. We sought to determine the rates of asymptomatic VF in patients suffering from AN, hypothesizing that VF rates would be higher in subjects with low bone mineral density (BMD) Z-scores. We recruited young women with AN (n = 80) for participation in a longitudinal trial. Dual-energy X-ray absorptiometry images of the lateral thoracic and lumbar spines were obtained for VF assessment at 0, 6, 12, and 18 mo. Thirteen subjects (16%) had a low spinal BMD at baseline (BMD Z-score ≤−2 standard deviation). Using the Genant semiquantitative technique, 2 of 80 subjects at baseline (2.5%) had evidence of a single Genant grade 1 deformity. One subject had a Genant grade 2 deformity. Over the 18-mo trial, 10 incident VFs occurred in 9 subjects (12.5%). Using quantitative techniques, only 2 subjects had a more than 15% loss in vertebral height. Neither anthropometric data nor markers of disease severity were associated with fracture. In conclusion, ill young women with AN were at low risk for asymptomatic VF in our cohort. VFs were not predicted by duration of illness, severity of malnutrition, or traditional measures of areal BMD at the lumbar spine.     

Bone mineral density in adults transplanted in childhood for liver disease

INTRODUCTION: It remains unclear whether bone mineral density (BMD) is compromised in adult life after liver transplantation (LT) during childhood. METHODS: This was a cross-sectional study of total body (TB) and lumbar spine (LS) dual-energy X-ray absorptiometry, anthropometry, and data collected, which included a physical activity questionnaire. RESULTS: Fifteen patients were enrolled. Mean age at LT was 10.6 (4.5) years (range 1.6 to 18.4). The mean posttransplant period was 12.0 (4.1) years (range 4.4 to 16.7); six were men. The mean TB BMD, 1.11 (0.12) g/cm2, was similar to LS BMD, 1.15 (0.17) g/cm2 (P=.82). The Z-score mean was lower for TB BMD, -0.92 (1.2), and LS BMD, -0.41 (1.2) (P=.22). There was no effect from gender, pretransplant cholestasis (9/15 cases), age at LT, and time since LT. BMD (Z-score) was better for those on corticosteroids (9/15 cases): TB BMD -0.42 (1.20) versus -1.77 (0.86) (P=.04); LS BMD 0.14 (1.00) versus -1.54 (1.03) (P=.03). Anthropometry Z-scores were height -0.04 (0.70), weight -0.33 (0.39), and BMI -0.32 (0.37). There was no correlation between Z-scores for BMD and any of the anthropometry parameters. CONCLUSION: Although the mean TB BMD was lower in transplanted patients than would be expected for the general population, overall BMD and anthropometry were with the normal adult ranges for adults who had undergone LT in childhood.     

Dental malocclusion is associated with reduced systemic bone mineral density in adolescents.

There is no published data about associations between the state of dentition and bone mass in adolescents. The objective of this study was to investigate whether the prevalence of caries and dental malocclusion is associated with bone mass during growth. In 123 healthy Caucasian subjects (72 males, 51 females) aged 14-18 yr, DMFT figures (decayed teeth, missing teeth, filled teeth) and presence of malocclusion, according to Angle classification, were determined. Participants completed a questionnaire regarding dental hygiene, physical activity level, and consumption of sweets. Anthropometry and pubertal stages were examined. Bone mineral density (BMD) was examined using dual energy X-ray absorptiometry (DXA) in the total body, head, and lumbar spine. No association was found between DMFT (mean+/-SD: 8.33+/-3.9) and BMD or Z-scores for BMD. Malocclusion was found in 49 subjects (39.8%) and was more prevalent in females than males. Malocclusion was associated with lower total BMD independently of body size (p=0.001; Z-scores: -0.21+/-0.27 vs +0.33+/-0.17; p=0.1) in males (but not females), producing odds ratio 1.6 (95% confidence interval: 1.09-2.34%; p=0.02). Head BMD was also lower in the males with malocclusion than in those without (p=0.004). Neither caries nor the tooth loss appear to be associated with BMD during growth. Boys with malocclusion are at higher risk of reduced BMD. This suggests that inadequate bone mass accrual in males coexists with impaired growth of the masticatory system in childhood and adolescence, however, the causal pathway is unknown. Factors that produce malocclusion may also affect bone mass or size but further prospective studies are needed to evaluate the relationship.     

Bone mineral density of proximal femur and spine in Korean children between 2 and 18 years of age

Ethnic factors affect bone mass acquisition during childhood. The aim of our study was to establish normative data for bone mineral content (BMC) and bone mineral density (BMD) in healthy Korean children and adolescents, using 446 lumbar spine scans (224 males and 222 females) and 364 proximal femur scans (181 males and 183 females) of healthy children between ages 2 and 18 years measured by dual-energy X-ray absorptiometry using Hologic QDR Discovery A 2004. There was an increase in both BMC and BMD during early childhood, acceleration during the adolescence spurt, and a slower increase later. Until 11 years of age, both male and female BMC and BMD were not statistically different. There was a rapid increase in both BMC and BMD in females earlier than in males, and later males caught up with the females and overshot the female values. When compared with Canadian children, BMD and BMC of total proximal femur was found to be more and BMD and BMC of total lumbar spine to be less at some ages. Tanner's stage was significantly associated with BMD and BMC of spine and proximal femur in males and BMC of spine in females in the first three Tanner's stages. Height, body weight, fat content, and body mass index influenced BMC and BMD at different sites by variable amount. Hence, the values presented in this study should be used as reference values in Korean children and adolescents.     

体重、身高对成都地区青壮年腰椎、髋部骨量的影响

目的　研究体重、身高对青壮年腰椎、髋部骨量的影响。方法　随机抽取成都地区年龄在 2 0～ 39岁 ,排除心肝肺肾、内分泌等慢性病、骨代谢疾病及脊椎畸形者 2 37名 (其中男性 10 8名 ,女性 12 9名 ) ,采用美国Lunar公司生产DPX L型双能X线骨密度仪测定受试者腰椎和髋部的骨矿含量 (BMC)、面积 (AREA)、骨密度 (BMD)。全部资料输入微机 ,用SPSS软件进行统计学处理。结果　体重、身高、体重指数 (BMI)与腰椎、髋部的BMC、Area、BMD呈正相关 ,其中体重与腰椎、髋部的BMC、Area中等程度相关 (r=0 39～ 0 5 5 ,P <0 0 1) ,身高与腰椎 (L2 - 4)AREA相关性最好 (r=0 75 8,P <0 0 1) ,体重、身高与BMD相关性差 (r=0 15 2～ 0 2 2 5 ,P <0 0 5 )。男性腰椎及髋部的BMC、AREA均明显高于同年龄组女性 (P <0 0 1) ,男、女L2 - 4BMD无显著性差异 (P >0 0 5 ) ,男性略低于女性。L2 - 4BMC与体重比值及L2 - 4AREA与体重比值 ,男、女无显著性差异 (P >0 0 5 )。L2 - 4Area与身高比值男性明显高于女性 (P <0 0 1)。结论　体重对青壮年BMC的影响大于身高 ,身高对L2 - 4AREA影响最大 ,男、女体重、身高的差异决定了峰值骨量的差异。BMC、Area、BMD 3项指标中 ,BMC更能反映体重、身高的差异 ,用BMC诊断骨质疏松     

DXA-Generated Z-Scores and T-Scores May Differ Substantially and Significantly in Young Adults

Central dual-energy X-ray absorptiometry (DXA) is the gold standard for non-invasive measurement of bone mineral density (BMD). Using this value and subject demographics, DXA software calculates T-scores and Z-scores. Professional society guidelines for the management of osteoporosis are based on T-scores and Z-scores, rather than on the actual BMD value. Although one expects T-scores and Z-scores to be very similar in young men and women for any given BMD measurement, little literature exists on this issue. Our clinical experience shows that some younger adult individuals (premenopausal women and men younger than 50 yr) have larger than expected difference between their DXA T-score and Z-score. This cross-sectional study evaluates the extent of this discordance between Z-scores and T-scores in a sample of 4275 men and women aged 20–49 yr. All subjects were scanned by central DXA using equipment manufactured by GE Lunar, GE, Madison, WI, or Hologic, Inc., Bedford, MA. Significant differences between Z-scores and T-scores were seen within individuals at the lumbar spine, total hip, femoral neck, and trochanter (p value < 0.001) for both DXA systems. Although these differences were less than half a standard deviation (SD) in most instances, the magnitude of difference was substantial at times, being 1 or more SD in up to 11% of cases (range: −1.95 to +1.54 SD). The smallest differences were seen at the total hip and the largest differences were seen at the femoral neck for both technologies. This is in part because there is no single standard Z-score definition, resulting in different methods of calculation across, and even within, DXA manufacturers. Standardization of Z-score definition and method of calculation is indicated. DXA Z-scores should be interpreted with caution in men and women aged 20–50 yr.     

High Degree of Discordance Between Three-Dimensional and Two-Dimensional Lumbar Spine Bone Mineral Density in Turner''s Syndrome

Low bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) has been described in Turner's syndrome (TS). One of the error factors of DXA is short stature, a common finding in TS patients. Aimed to evaluate the influence of a low stature on BMD, we compared the two-dimensional (2D) or conventional BMD (cBMD) with three-dimensional (3D) or volumetric BMD (vBMD) in 62 females (10 to 48 yr old) with TS diagnosis in a case control study. They were compared to 102 normal females (7 to 45 yr old) grouped by age-ranges. All patients were subjected to a lumbar spine densitometry by DXA in the PA and lateral projections, obtained the cBMD and vBMD and calculated for the apparent BMD (appBMD). In TS, the mean of Z-score for cBMD was significantly lower than that for vBMD and for appBMD (-2.31 +/- 1.42; -0.64 +/- 1.55; and -1.72 +/- 1.5; respectively). Most of the patients (83.8%) had a Z-score <-1 for cBMD, whereas the majority (58.1%) had a Z-score <-1 for vBMD. Concluding, the cBMD underestimates the bone mass of the lumbar spine in patients with TS inducing to false diagnoses of bone fragility. Volumetric BMD approached the bone mass of control patients, while appBMD just partially do that.     

The non-steroidal antiandrogen,bicalutamide ('Casodex'), may preserve bone mineral density as compared with castration: results of a preliminary study

The impact of bicalutamide (Casodex) monotherapy on bone mineral density (BMD) was investigated in patients with locally advanced prostate cancer. BMD was assessed after treatment with bicalutamide 150 mg daily ( n=21) or by medical castration (goserelin acetate 3.6 mg every 28 days) ( n=8) for a median of 287 weeks. In 38% of castration compared with 17% of bicalutamide patients, femoral neck Z-scores were < or =-1 SD of the reference value (accepted as a two to three times increased risk of fracture) and T-scores were < or =-2.5 SD (World Health Organization definition of osteoporosis in white females). Total hip Z-scores were < or =-1 in 43% of castration patients and 13% of bicalutamide patients. In 38% of patients, lumbar spine BMD was affected by degenerative disease. These preliminary data suggest that there may be an advantage in terms of BMD in using bicalutamide monotherapy compared with castration; a benefit confirmed in a recent prospective randomised study.     

Indeterminate colitis (nonspecific inflammatory bowel disease)

Distinguishing of indeterminate colitis from ulcerative colitis or Crohn's disease in more than 10% of IBD cases as separate diagnostic category (IIBD) is defined by: first, overlapping or paucity of features of two major IBD forms in acute fulminant colitides and few chronic slowly progressive cases without differentiating markers of chronicity, and second, inability to reach specific diagnosis during or after completed clinical, radiological, endoscopical and histopathological examination of chronic colitis with inconclusive presentation of IBD-compatible cases. It implicates the contemporary category of IIBD, until some new relevant data of further clinical (preferably natural history and course of the disease) and histopathological examination of prior biopsies will possibly reclassify 20-75% of these cases into ulcerative colitis category (up to 40%) or Crohn's disease (up to 25%) at a median of 10 years' follow-up. The presence of ileal and/or perianal disease as well as later evident granulomatous and/or fissuring disease, including cases with pouchitis and diversion colitis in addition, could be helpful in favouring of Crohn's disease. Lacking specific signs of disease, IIBD is not a distinct entity. Still, many patients remain in this category. The most far is acute fulminant disease in adolescents and young adults with unusual distribution of transmural inflammation with deep fissuring ulcerations, sometimes of "collar-stud" type and normal mucosa between them, often with relative rectal sparing. There is significant risk of relapse and complications, but mild clinical course and even spontaneous regression are also reported. Failure of ileal pouch-anal anastomosis surgery is about 20% more frequent then in ulcerative colitis with overall worse prognosis in life expectations. Diagnostic problems and the main presentations are discussed in detail, as well as genetic and etiopathogenetic basis for heterogeneity of IBD.     

Discordance in lumbar spine T-scores and nonstandardization of standard deviations.

Previous studies have demonstrated differences in proximal femur bone mineral density T-scores depending on the reference range used. This subsequently was addressed by the recommended adoption of the National Health and Nutrition Examination Survey III reference range. There is, however, no accepted reference range for interpretation of lumbar spine bone mineral density (BMD), and the use of different reference populations by different manufacturers could result in inconsistencies in diagnosis of osteopenia or osteoporosis. We compared lumbar spine BMD, as well as T- and Z-scores, in 59 women measured using Lunar DPXL and Norland Excel densitometers. BMD measured by the instruments was highly correlated (r = 0.98, p < 0.0001). The instruments however assigned significantly different values when BMD was expressed as T-scores. There were also significant differences in BMD assignments between instruments, when expressed as Z-scores. The observed differences relate to the different young normal mean, and SD employed in calculating the T- and Z scores. To conclude, in the lumbar spine, two commonly used DXA instruments provide comparable absolute values but there are significant differences in derived T-scores due to differences in manufacturer- specific reference ranges. There is a need for standardization of the reference ranges used in the lumbar spine.     

A comparison of spinal quantitative computed tomography with dual energy X-ray absorptiometry in European women with vertebral and nonvertebral fractures

Quantitative computed tomography (QCT) was compared to dual X-ray absorptiometry (DXA) measured in the lumbar spine of 508 European women defined as normal without fracture (NoF), or osteoporotic (OP), with either vertebral fracture (VF), or peripheral fracture (PF). The correlations between QCT and DXA BMD measurements were significantly different in normal and in osteoporotic patients, indicating that the two exams do not measure the same bone aspects. According to ROC curves results, QCT Z-scores separate OP from NoF with better sensitivity than all other measurements. A threshold to differentiate OP from NoF was chosen at Z-score=−1 for DXA-BMD and −1.5 for QCT-BMD. VF patients showed a highly significant decrease in BMD by DXA or QCT. PF patients revealed measurements lower than those of normal subjects but greater than those of VF, calling into question the idea of a diffuse osteoporosis causing nonvertebral fractures that is measurable by spinal DXA or QCT. DXA is weakly dependent upon age, and T-score or Z-score are equivalent for evaluating osteoporosis. QCT depends greatly upon age, and Z-score appears to be more efficient.