Bone Mineral Affection in Asymptomatic Adult Patients with Celiac Disease

Objectives: Osteopenia is a well-known complication of overt celiac disease, but whether such defective bone mineralization is present among asymptomatic or silent patients is not known. Our objectives were: 1 ) to examine bone mineralization of a group of asymptomatic celiac patients; 2 ) to compare these results with those of symptomatic patients. Methods: Bone mineral density of the spine and total skeleton by dual energy x-ray ab-sorptiometry and serum parameters of mineral metabolism of eight recently diagnosed asymptomatic patients with celiac disease were studied. Results were compared with those obtained in 20 untreated symptomatic celiacs, 14 patients treated with gluten-free diet for a mean time of 15 yr, and 153 healthy adult subjects, matched by sex and age. Results: Four and five out of eight asymptomatic patients presented with reduced mineralization of the spine and the total skeleton, respectively (>1 SD below normal values for sex and age). Two patients presented with severe osteopenia of the spine, and the other three presented with severe osteopenia of the whole skeleton (>2 SD below mean normal values). Osteopenia at plane bone level (total skeleton) was significantly lower when compared to healthy controls ( P < 0.02). Symptomatic untreated patients had significantly more severe deterioration of bone mineralization than did asymptomatics ( P < 0.05) and treated patients ( P < 0.05). No difference in bone mineral density was observed between treated patients and asymptomatic celiacs. Serum levels of calcium, alkaline phosphatase, 25-OH vitamin D, and parathormone did not show conclusive abnormalities. Conclusions: Our findings provide direct evidence that reduced bone mineralization occurs in asymptomatic celiac patients before any other symptom becomes evident. Only early diagnosis and treatment of celiac disease can avoid the deterioration of the bone structure observed in all clinical status of celiac disease.     

The prevalence of vertebral fractures in mild ankylosing spondylitis and their relationship to bone mineral density

OBJECTIVE: To determine bone mineral density (BMD) in patients with mild ankylosing spondylitis (AS), to establish the prevalence of vertebral fractures and fracture risk in these patients, and to determine the relationship between BMD and vertebral fractures. METHODS: Sixty-six men with mild AS were studied. BMD of the lumbar spine and femoral neck was measured by dual X-ray absorptiometry (DXA) and radiographs of the thoracic and lumbar spine were obtained in all subjects. From the radiographs, vertebral fractures were characterized by a morphometric technique using established criteria. Thirty-nine healthy male subjects aged 50-60 yr, recruited from primary care registers, had spinal radiographs performed and served as controls for vertebral fractures. RESULTS: In patients with AS, BMD was reduced in both the lumbar spine 0.97 (0.1) g/cm(2) [T score -1.10 (1.3), 95% confidence interval (CI) -0.50, +0.14] and femoral neck 0.82 (0.1) g/cm(2) [T score -1.40 (1.2), 95% CI -0.51, +0.09]. There was no correlation between BMD of either the lumbar spine or femoral neck and duration of disease in patients with AS. Eleven of 66 (16.7%) patients with AS had a vertebral fracture, compared with one of 39 (2.6%) controls; odds ratio 5.92 (95% CI 1.4, 23.8). AS patients with fractures were not significantly older (mean age 41.4 vs 37.8 yr, P=0.17), but had significantly longer disease duration (12.4 vs 9.3 yr, P<0.05) than patients without fractures. No significant difference was found in the visual analogue scores for pain in AS patients with fractures compared with those without. No significant correlation was observed between BMD of the lumbar spine or femoral neck and vertebral fractures in patients with AS. In addition, there was no significant difference in the lumbar spine or femoral neck BMD in AS patients with fractures compared with those without. CONCLUSIONS: Spinal and hip osteopenia and vertebral fractures are a feature of mild AS. However, there was no correlation between BMD and vertebral fractures in these patients. AS patients with mild disease had a higher risk of fractures compared with the normal population and this increased with the duration of disease.     

Bone demineralization and vertebral fractures in endogenous cortisol excess: role of disease etiology and gonadal status

INTRODUCTION: The effects of endogenous cortisol (F) excess on bone mass and vertebral fractures have still not been thoroughly investigated. The aim of this cross-sectional case-control study was to investigate factors influencing bone demineralization and vertebral fractures in different conditions of F excess, i.e. Cushing's disease and adrenal and ectopic Cushing's syndrome. MATERIALS AND METHODS: Eighty consecutive patients and 80 controls were prospectively enrolled: 37 patients (21 females) with pituitary ACTH-secreting adenoma, 18 (14 females) with adrenocortical adenoma, 15 (11 females) with adrenal carcinoma of mixed secretion, and 10 (three females) with ectopic ACTH secretion. The groups had similar age. At diagnosis, bone mineral density (BMD) was determined by the dual-energy x-ray absorptiometry technique at the lumbar spine (L1-L4) and femoral neck; vertebral fractures were investigated by standard spinal radiographs. RESULTS: When comparing the groups with different etiology of F excess, the patients with ectopic ACTH secretion had higher F and lower BMD values than the other subgroups. Morning F (P = 0.03) and testosterone levels (P = 0.04) correlated with lumbar BMD. Vertebral fractures were found in 61 (76%) of the patients, were multiple in 52 (85%) of the cases, and clinically evident in 32 (52%). Only multiple fractures were more frequent in patients with ectopic ACTH hypersecretion (P < 0.05). Lumbar spine BMD was the best predictor of vertebral fractures (P < 0.01). Surprisingly, amenorrheic and eumenorrheic women had similar BMD values and fracture prevalence. CONCLUSION: A high prevalence (76%) of vertebral fracture was revealed, regardless of the etiology of the patients' hypercortisolism. The harmful effects of F excess at the spine were partly counterbalanced by the increased androgen production but were not affected by gonadal status in women.     

Femoral bone mineral density is associated with vertebral fractures in patients with ankylosing spondylitis: a cross-sectional study

OBJECTIVE: To determine the association between vertebral fractures and clinical, laboratory, and radiological variables in patients with ankylosing spondylitis (AS). METHODS: Sixty-eight men with AS and 91 sex- and age-matched controls were consecutively enrolled. Vertebral fractures were assessed according to a visual semiquantitative grading system using plain radiographs of the lumbar spine obtained from patients with AS. Disease activity variables including C-reactive protein, erythrocyte sedimentation rate, finger-to-ground distance score, Schober's Index score, Bath Ankylosing Spondylitis Radiology Index for the spine (BASRI-s) score, and syndesmophyte score were identified. Assessments of bone mineral density (BMD) of the lumbar spine and the femur in patients and controls were performed using an anteroposterior dual energy x-ray absorptiometry technique. RESULTS: Eleven patients (16.2%) out of the total of 68 patients with AS had vertebral fractures; these were identified as wedge deformities (n = 5) or biconcave (n = 6) deformities. BMD levels of the lumbar spine and femur in patients were significantly reduced compared with those of age-matched controls. There were significant differences in the Schober's Index scores, finger-to-ground distance scores, BASRI scores of the lumbar spine, syndesmophyte scores, and intertrochanter values of BMD among AS patients both with and without vertebral fractures. Multiple logistic regression analyses revealed that intertrochanteric BMD values also were independently associated with vertebral fractures in AS (p = 0.041). CONCLUSION: We demonstrated evidence of a correlation between low femoral BMD levels and risk of vertebral fractures in patients with AS, especially at the intertrochanteric area. Longitudinal studies in a large population are required to determine the diagnostic implications of femur BMD for increased risk of vertebral fractures in AS.     

Bone mineral density in ankylosing spondylitis

Summary Vertebral osteoporosis is a well-recognized feature of ankylosing spondylitis (AS) and also the vertebral compression fractures due to osteoporosis are a common but frequently unrecognized complication of AS. Both may contribute to the pathogenesis of spinal deformity and back pain. The aim of this study was to measure vertebral and femoral neck bone mass in patients with AS by dual photon absorptiometry, to determine the prevalence of compression fractures and to examine the relationship between bone density and disease severity. We found that the bone mass was diminished in the lumbar spine in moderate AS versus mild forms but the patients with advanced disease had the highest BMD values. Examination of spinal radiographs revealed compression and biconcave fractures in 9 (40.9%) cases. Neither the duration of the disease and the degree of sacroiliitis, nor the disease activity assessed by laboratory and clinical parameters was found to significantly affect the results.     

Men suffer vertebral fractures with similar spinal T-scores to women

OBJECTIVE: To evaluate the applicability of the WHO densitometric criteria for the diagnosis of spinal osteoporosis in men and to compare it with women with vertebral fractures, as well as to analyze the role of vertebral dimensions in the development of spinal fractures. METHODS: For these purposes we analyzed, using DXA, vertebral projected area and lumbar bone mineral density (BMD), as well as T and Z-scores in lumbar spine in a cohort of 66946 individuals; 2556 of these subjects had one or more atraumatic vertebral fracture (396 men and 2160 postmenopausal women). RESULTS: Men and women with fractures showed significantly lower mean BMD, T-score and Z-score values than individuals without fractures while vertebral dimensions were similar in both groups of patients. When comparing men and women with vertebral fractures, the former showed a significantly greater projected area (46.89+/-5.5 vs. 39.13+/-4.6 cm(2) p<0.001) and lumbar BMD (0.991+/- 0.21 vs. 0.938+/- t0.19 g/cm(2) p<0.001). However, the median lumbar T-score values were similar for both sexes (-2.3 in women vs. -2.2 in men; p: NS). In addition, a similar percentage of men and women with vertebral fractures showed T-score values <-2.5 in the lumbar spine (44% vs. 46%, p=NS). CONCLUSION: We conclude that although men with vertebral fractures have greater vertebral dimensions and BMD than women, the lumbar T-scores are similar. Therefore, it seems reasonable to adopt the same T-score values for the diagnosis of osteoporosis in men and women.     

Effect of gonadal status on bone mineral density and radiological spinal deformities in adult patients with growth hormone deficiency

Growth hormone deficiency (GHD) in adult patients is associated with marked decrease in bone turnover, low bone mass and high risk of clinical and subclinical fractures. We investigated whether the prevalence of spinal deformities in adults with GHD was related to the gonadal status of patients. A total of 89 adult hypopituitary patients with severe GHD were evaluated for bone mineral density (BMD) and vertebral deformities (quantitative morphometric analysis). At the study entry, 54 patients were eugonadic whereas 35 patients were hypogonadic without replacement treatment. Radiological spinal deformities were found in 55 patients (61.8%) with higher prevalence in untreated (56 cases) versus treated (33 cases) GHD patients. Eugonadic and hypogonadic patients showed no significant difference in spinal deformities although T-score was significantly lower in hypogonadic as compared with eugonadic patients. Gonadal function was not correlated with the occurrence of spinal deformities which was instead inversely correlated with rhGH treatment. In conclusion, gonadal status may influence BMD in adult patients with GHD without affecting the risk to develop vertebral deformities. Conversely, rhGH replacement treatment seems to be the only factor influencing the risk to develop vertebral deformities in adult GHD patients.     

High prevalence of osteoporotic vertebral fractures in patients with Crohn's disease

BACKGROUND AND AIMS: Osteopenia and osteoporosis are frequent in Crohn's disease. However, there are few data on related vertebral fractures. Therefore, we evaluated prospectively the prevalence of osteoporotic vertebral fractures in these patients. METHODS: A total of 293 patients were screened with dual energy x ray absorptiometry of the lumbar spine (L1-L4) and proximal right femur. In 156 patients with lumbar osteopenia or osteoporosis (T score <-1), x ray examinations of the thoracic and lumbar spine were performed. Assessment of fractures included visual reading of x rays and quantitative morphometry of the vertebral bodies (T4-L4), analogous to the criteria of the European Vertebral Osteoporosis Study. RESULTS: In 34 (21.8%; 18 female) of 156 Crohn's disease patients with reduced bone mineral density, 63 osteoporotic vertebral fractures (50 fx. (osteoporotic fracture with visible fracture line running into the vertebral body and/or change of outer shape) and 13 fxd. (osteoporotic fracture with change of outer shape but without visible fracture line)) were found, 50 fx. in 25 (16%, 15 female) patients and 13 fxd. in nine (5.8%, three female) patients. In four patients the fractures were clinically evident and associated with severe back pain. Approximately one third of patients with fractures were younger than 30 years. Lumbar bone mineral density was significantly reduced in patients with fractures compared with those without (T score -2.50 (0.88) v -2.07 (0.66); p<0.025) but not at the hip (-2.0 (1.1) v -1.81 (0.87); p=0.38). In subgroups analyses, no significant differences were observed. CONCLUSIONS: In patients with Crohn's disease and reduced bone mineral density, the prevalence of vertebral fractures-that is, manifest osteoporosis-was strikingly high at 22%, even in those aged less than 30 years, a problem deserving further clinical attention.     

The threshold of bone mineral density for vertebral fractures in female patients with primary hyperparathyroidism

BACKGROUND AND OBJECTIVE: Primary hyperparathyroidism (pHPT) is one of the causal diseases that induce secondary osteoporosis. Although patients with pHPT have reduced bone mineral density (BMD) especially at the cortical bone, there have been controversies about risk of fracture. Moreover, no reports have been available about the threshold of BMD for fractures in pHPT patients. METHODS: BMD values were measured by dual-energy x-ray absorptiometry at lumbar spine, femoral neck and distal one third of radius. Various indices were compared in 116 female pHPT patients and 716 control subjects. Moreover, we analyzed relationship between the cut-off values of BMD and the prevalence of vertebral fractures in pHPT and control subjects. RESULTS: The prevalence of subjects with vertebral fractures was lower in pHPT patients, compared with that of control subjects. Age and body height were significantly higher and lower in pHPT women with vertebral fractures, respectively. Lumbar spine BMD was significantly lower in pHPT women with vertebral fractures, presumably due to their increased age. There were no differences in femoral neck and radius BMD or in bone metabolic indices between pHPT women with and without vertebral fractures. On the other hand, age-matched BMD was not significantly different between both groups at any measured site. Cut-off values of BMD at lumbar spine and femoral neck were lower in postmenopausal pHPT patients, compared with those of the postmenopausal control group. Moreover, cut-off values of BMD at radius was much lower in postmenopausal pHPT patients, compared with those of the postmenopausal control group (pHPT vs control (g/cm(2)): 0.670 vs 0.706 at lumbar spine; 0.549 vs 0.570 at femoral; 0.394 vs 0.474 at radius). Sensitivity and specificity of vertebral fractures was lower in pHPT patients, compared with those in control group. CONCLUSIONS: The present cross-sectional study demonstrated that thresholds of BMD for vertebral fractures were lower especially at radial bone in female patients with pHPT, compared with those in the control group.     

Bone mineral density and vertebral compression fracture rates in ankylosing spondylitis.

OBJECTIVE--To examine the relationship between disease severity and bone density as well as vertebral fracture risk in patients with ankylosing spondylitis (AS). METHODS--Measurements were taken for bone mineral density (BMD) and vertebral fracture rates in 87 patients with AS. BMD was measured at the hip (femoral neck -FN), lumbar spine (L1-L4-LS) and for the whole body using a hologic-QDR-1000/W absorptiometer. An algorithm based on normal female ranges of vertebral heights was used to define a fracture as occurring when two vertebral ratios were each three standard deviations below the calculated mean of the controls. RESULTS--Patients with AS had significantly lower FN-BMD in proportion to disease severity (based on a Schober index) and disease duration. LS-BMD was also reduced in early disease, but in patients with advanced AS it had increased considerably. Nine vertebral fractures (10.3%) were identified which was considerably higher than expected when compared with a fracture of 1.9% in a control population of 1035 females of a similar age range. Patients with AS with fractures were significantly older, more likely to be male, had longer disease duration and more advanced spinal limitation with less mobility. There was no significant reduction in lumbar spine or femoral neck bone density in the fracture group. CONCLUSIONS--Vertebral fractures that result from osteoporosis are a feature of longstanding AS. BMD used as a measure of osteoporosis of the spine in advanced AS is unreliable probably as a result of syndesmophyte formation and does not predict the risk of vertebral fracture. Alternative sites such as the neck of the femur should be used for sequential assessment of BMD in AS.     

Prevalence of and risk factors for low bone mineral density and vertebral fractures in patients with systemic lupus erythematosus

OBJECTIVE: To examine the prevalence of and risk factors for low bone mineral density (BMD) and vertebral fractures in patients with systemic lupus erythematosus (SLE). METHODS: We studied 107 SLE patients. Demographic and clinical data were collected, and radiographs of the thoracic and lumbar spine and BMD measurements by dual x-ray absorptiometry were performed. Vertebral deformities were scored according to the method of Genant et al: fractures were defined as a reduction of > or = 20% of the vertebral body height. Osteoporosis was defined as a T score less than -2.5 SD and osteopenia as a T score less than -1.0 SD in at least 1 region of measurement. RESULTS: Osteopenia was present in 39% of the patients and osteoporosis in 4% (93% female; mean age 41.1 years). In multiple regression analysis, low BMD in the spine was associated with a low body mass index (BMI), postmenopausal status, and 25-hydroxyvitamin D deficiency. Low BMD in the hip was associated with low BMI and postmenopausal status. At least 1 vertebral fracture was detected in 20% of the patients. Vertebral fractures were associated with ever use of intravenous methylprednisolone and male sex. CONCLUSION: Risk factors for low BMD in SLE patients are low BMI, postmenopausal status, and vitamin D deficiency. While osteoporosis defined as a low T score was found in only 4% of the patients, osteoporotic vertebral fractures were detected in 20%. The high prevalence of low BMD and vertebral fractures implies that more attention must be paid to the prevention and treatment of osteoporosis and fractures in SLE.     

VERTEBRAL OSTEOPOROSIS IN RHEUMATOID ARTHRITIS PATIENTS: EFFECT OF LOW DOSE PREDNISONE THERAPY

The effect of low dose prednisone therapy on spinal bone massis controversial. We measured lumbar trabecular and corticalbone mineral density (BMD) in 74 rheumatoid arthritis (RA) patientsby dual energy quantitative computerized tomography in a cross-sectionalstudy. The presence of vertebral deformities was evaluated ona lateral spine radiograph. Patients who had never been treatedwith corticosteroids (n=44) were compared with patients on long-termlow dose ( 10 mg/day) prednisone therapy (n=30). After correctionfor confounding variables the lumbar BMD was highly sig nilicantlyinfluenced by prednisone therapy in postmenopausal patients(estimated influence –31.2% on trabecular BMD and –37.2%on cortical BMD). Vertebral deformities were also significantlymore frequent in prednisone treated postmenopausal patients.No negative effect of prednisone treatment could be demonstratedin male patients. In contradiction to previous reports we concludethat long-term prednisone therapy may be associated with developmentof spinal osteoporosis in postmenopausal RA patients, even whenlow doses are used. KEY WORDS: Corticosteroids, Osteoporosis, Bone densitometry, Dual energy quantitative computerized tomography, Vertebral fractures, Postmenopause     

Measurements of bone mass and bone density

X-ray-based procedures are available to measure bone mineral density in vitro at almost any skeletal site. These bone density measurements are not useful in the diagnosis of the cause of bone loss but at present are the only tests available for assessing bone mass prior to the occurrence of irreversible changes such as fractures or vertebral compression, which are easily recognizable on x-rays. When fractures are present, the severity of the bone loss and the risk for future fractures can be assessed. Repeated measurements permit estimation of the rate of bone loss, which gives useful information for monitoring treatment effect or course of the disease. Measurement of total body calcium is of less clinical importance because of the predominantly trabecular bone loss that generally occurs in metabolic bone disease. Dual-energy x-ray absorptiometry (DEXA) and quantitative computed tomography (QCT) of the spine are of about equal clinical value in the first approach to the patient with metabolic bone disease, although DEXA allows greater variety in sampling sites. For repeated measurements, DEXA provides better precision at significantly lower radiation burden. For bone mineral measurements, the lumbar spine appears to be the most sensitive skeletal site.     

2型糖尿病患者血戊糖素水平与椎体骨折的研究

目的 探讨2型糖尿病患者骨密度的变化,研究血戊糖素与2型糖尿病患者椎体骨折的相关性.方法 选取100例2型糖尿病患者作为糖尿病组,另选取70名非糖尿病者作为对照组,受试者年龄均大于60岁.所有受试者均行胸腰椎X线检查以确定椎体骨折,同时检测受试者的腰椎骨密度,抽取空腹静脉血查戊糖素及骨代谢指标.判断两组腰椎骨密度、椎体骨折发生率的差异,同时分析血戊糖素水平与椎体骨折的相关性.结果 两组的年龄、体重指数、骨代谢指标、骨密度水平差异均无统计学意义(P均＞0.05).糖尿病组戊糖素水平及椎体骨折的发生率均较对照组明显升高(t =5.764,x2=6.286,P均＜0.05).相关性分析提示,椎体骨折与戊糖素水平呈正相关(r=0.236,P=0.018).回归分析显示,椎体骨折与戊糖素水平独立相关(OR=1.008,95％ CI:1.001～ 1.015,P=0.032).结论 血戊糖素可能作为老年2型糖尿病患者椎体骨折风险评估的指标.     

High prevalence of vertebral deformity in premenopausal systemic lupus erythematosus patients

In this paper we searched for vertebral deformities in a group of 70 premenopausal systemic lupus erythematosus (SLE) patients (31.8 +/- 8.1 years old) and compared them to a matched control group of 22 healthy women (32.0 +/- 8.9 years old). Patients and controls performed spine X-ray (XR) morphometry and lumbar spine and femoral neck bone mineral density (BMD). Clinical data was obtained by a questionnaire and charts review. Thoracic or lumbar spine fracture was observed in 15 (21.4%) SLE patients, while no deformities were found in the control group (P = 0.018). BMD was not different amongst SLE patients and controls and between SLE patients with or without deformities. Although BMD could not predict what patient have deformity, seven patients (46.6%) with deformity had a lumbar spine or femoral neck Z-score less than - 1 SD [median = -0.59 (-3.72 to +0.88) and -0.20 (-4.05 to + 1.87)] respectively. In addition, we found a negative correlation between number of fracture per patient and lumbar spine and femoral neck BMD (R = 0.58, P = 0.04 and R = 0.84, P = <0.0001 respectively). No significant correlation was found between number of deformities and clinical data. This is the first study to search for vertebral deformities in SLE patients and to demonstrate a high prevalence of deformities in a relative young SLE population. These findings bring up the necessity to look for spine deformities in this group of women regardless the BMD.     

Effects of sex steroids on bone in women with subclinical or overt endogenous hypercortisolism

OBJECTIVE: Glucocorticoid-induced osteoporosis is the most frequent cause of secondary osteoporosis. Nevertheless, limited data are available on bone status in patients with endogenous cortisol excess. This study is aimed at investigating the role of sex steroids and severity of hypercortisolism on bone mineral density (BMD) and prevalence of vertebral fractures in female patients. DESIGN: Cross-sectional, case-control study. Patients: Seventy-one consecutive women were enrolled: 36 with overt hypercortisolism (26 with ACTH-secreting pituitary adenoma and 10 with cortisol-secreting adrenal tumor) and 35 with subclinical hypercortisolism due to adrenal incidentalomas. They were compared with 71 matched controls. METHODS: At diagnosis, we measured serum cortisol, FSH, LH, estradiol, testosterone, androstenedione and DHEAS, and urinary cortisol excretion. BMD was determined by dual energy X-ray absorptiometry at the lumbar spine and femoral neck. Vertebral fractures were investigated by a semiquantitative scoring method. RESULTS: Between women with overt and subclinical hypercortisolism BMD values and prevalence of any vertebral (69 vs 57%, P = 0.56), clinical (28 vs 11.4%, P = 0.22), and multiple vertebral fractures (36 vs 31%, P = 0.92) did not differ. Among patients with subclinical hypercortisolism, amenorrhoic women had a lower BMD (P = 0.035) and more frequent vertebral fractures (80 vs 40%; P = 0.043) when compared with the eumenorrhoic ones. Among women with overt hypercortisolism, there was no difference in lumbar BMD (P = 0.37) and prevalence of fractures (81 vs 60%; P = 0.26) between those amenorrhoic and eumenorrhoic. By logistic regression analysis, lumbar spine BMD values and cortisol-to-DHEAS ratio were the best predictors of vertebral fractures (P < 0.01). CONCLUSIONS: Vertebral fractures are very common in women with endogenous cortisol excess, regardless of its severity. The deleterious effects of hypercortisolism on the spine may be partly counterbalanced by DHEAS increase at any degree of cortisol excess, and by preserved menstrual cycles in women with subclinical but not in those with overt hypercortisolism.     

Bone density and bone metabolism are normal after long-term gluten-free diet in young celiac patients

OBJECTIVES: Osteoporosis and alterations of bone metabolism are frequent complications of celiac disease. We evaluated the impact of long-term gluten-free diet (GFD) initiated during childhood and adolescence on bone mineralization and bone metabolism. METHODS: We studied 30 celiac patients on GFD for > or = 5 yr. The mean age at diagnosis was 11.4+/-5.0 yr, and the mean duration of GFD was 10.7+/-4.3 yr. Results were compared with those obtained in 240 healthy controls. Bone mineral density (BMD) was measured in the lumbar spine and in the whole skeleton by dual-energy x-ray absorptiometry. Serum levels of bone-specific alkaline phosphatase (BALP) and N-terminal propeptide of type I procollagen (PINP) were measured as bone formation indices, and urine levels of N-telopeptide of type I collagen (NTx) as bone resorption index. RESULTS: BMD measurements of celiac patients (lumbar spine: 1.131+/-0.121 g/cm2; total body: 1.145+/-0.184 g/cm2) did not differ from those of control subjects (lumbar spine: 1.131+/-0.184 g/cm2; total body: 1.159+/-0.118 g/cm2). The levels of BALP, PINP, and NTx of celiac patients did not differ from those of controls. Patients who started GFD before puberty had BMD and bone metabolism measurements comparable to those of patients who started GFD during puberty. CONCLUSIONS: Our data show that long-term dietary treatment ensures normal mineralization and bone turnover.     

Quantitative ultrasound of the proximal phalanges and dual-energy X-ray absorptiometry in Crohn's disease patients with osteopenia

Background: Osteopenia and osteoporosis are frequent complications in Crohn's disease, and these features are associated with an increased risk of vertebral and appendicular fractures. Bone mineral density (BMD) measurements are widely accepted to assess the fracture risk in postmenopausal osteoporosis. In recent years, quantitative ultrasound (QUS) has become attractive for the diagnosis of osteopenia as a nonionizing method. The aim of the present study was to investigate QUS and BMD measurements in osteopenic patients with Crohn's disease. Methods: BMD of the lumbar spine and femoral neck and QUS of proximal phalanges II-V (DBM Sonic 1200; IGEA) were performed prospectively in 171 patients with Crohn's disease. The amplitude-dependent sound-of-speed (AD-SoS) and the ultrasound bone profile score (UBPS) were calculated using the WinSonic PRO 1.1 software program. X-ray examination of the spine was performed in 131 patients. Vertebral deformity was morphometrically defined according to the published methods of McCloskey and Eastell. Results: BMD of the lumbar spine and femoral neck correlated significantly (r = 0.62), but no correlation between BMD and QUS could be demonstrated. Vertebral deformities (VD) were detected in 28/131 (21.4%) patients. Two patients had a history of femoral fracture (FF). Lumbar BMD was lower in patients with either VD or FF than in those patients with no preexisting fractures (T-score: −2.46 vs −2.04; P = 0.0233). QUS parameters correlated negatively to patients' age but could not be used to discriminate between patients with and without VD/FF. Conclusions: Osteoporosis-related fractures are associated with a low lumbar bone density in Crohn's disease patients. QUS of the proximal phalanges cannot detect manifest osteoporosis in Crohn's disease patients and is therefore not valuable as a screening tool for these patients. Received: January 10, 2002 / Accepted: August 30, 2002 Acknowledgments. Morphometry of vertebral radiographs was supported by the Osteoporosis Study Group of the Clinic for Radiology and Nuclear Medicine, Klinikum Benjamin Franklin, Berlin, Germany. Reprint requests to: C. von Tirpitz     

How should clinicians manage osteoporosis in ankylosing spondylitis?

Osteoporosis is a common complication of AS, with an incidence between 18.7% and 62%. The prevalence of osteoporosis is greater in males, and increases with increasing patient age and disease duration. Osteoporosis is also more common in patients with syndesmophytes, cervical fusion, and peripheral joint involvement. These variables are not all independent, as they may be indicators of disease duration. Osteoporosis in patients with AS is largely confined to the axial skeleton, in contrast to the pattern of osteoporosis seen in rheumatoid arthritis. BMD at the lumbar spine and femoral neck may be severely reduced, while most studies indicate that carpal and radial BMD remain within normal limits. The development of syndesmophytes in late AS can lead to difficulties in the use of DEXA scanning to determine lumbar BMD, as the extraspinal bone may obscure osteoporotic vertebrae. Under these circumstances more accurate assessment of lumbar BMD, and one that correlates better with femoral neck BMD, may be obtained by quantitative CT scanning or DEXA scanning of the lateral aspect of the L3 vertebra. Osteoporosis in AS significantly increases the risk of vertebral compression fractures within 5 years of the diagnosis of AS. The risk of a vertebral compression fracture occurring over a 30 year period following the diagnosis of AS is 14%, compared to 3.4% for population controls. In patients with vertebral osteoporosis relatively minor trauma, such as slipping, can lead to spinal fracture and dislocatior with subsequent damage to the spinal cord. There is a higher incidence of spinal cord injury following spinal fracture dislocations in patients with AS, and the resulting neurological deficit can range from mild sensory loss to complete paraplegia. Cytokines such as TNF-alpha and IL-6 may play an important part in the pathogenesis of osteoporosis in early AS, and IL-6 levels have been correlated with markers of disease activity and severity. In late AS, mechanical factors such as decreased mobility and the support provided by extraspinal bone may play a role in vertebral osteoporosis. Screening patients with AS for the presence of osteoporosis is an important, but contentious subject. This and subsequent monitoring needs to be considered in all patients, but longterm studies are needed to determine with confidence which patients should undergo screening, by which methods, and how often. The treatment of osteoporosis in AS is at present similar to that used for primary osteoporosis, except that due to the male predominance and a relatively young age of patients, there is a limited role for hormone replacement therapy. Exercise regimens and bisphosphonates are widely used, but a study of the relative efficacy of different bisphosphonate agents in patients with AS is required.     

High prevalence of morphometric vertebral deformities in patients with inflammatory bowel disease

BACKGROUND: Earlier studies have documented that the prevalence of decreased bone mineral density (BMD) is elevated in patients with inflammatory bowel disease. The objective of this study was to investigate the prevalence of vertebral deformities in inflammatory bowel disease patients and their relation with BMD and bone turnover. METHODS: One hundred and nine patients with Crohn's disease (CD) and 72 with ulcerative colitis (UC) (age 44.5+/-14.2 years) were studied. BMD of the hip (by dual X-ray absorptiometry) was measured and a lateral single energy densitometry of the spine for assessment of vertebral deformities was performed. Serum markers of bone resorption (carboxy-terminal cross-linked telopeptide of type I collagen) and formation (procollagen type I amino-terminal propeptide) were measured, and determinants of prevalent vertebral deformities were assessed using logistic regression analysis. RESULTS: Vertebral deformities were found in 25% of both CD and UC patients. Comparing patients with and without vertebral deformities, no significant difference was found between Z-scores and T-scores of BMD, or levels of serum carboxy-terminal cross-linked telopeptide of type I collagen and serum procollagen type I amino-terminal propeptide. Using logistic regression analysis the only determinant of any morphometric vertebral deformity was sex. The presence of multiple vertebral deformities was associated with older age and glucocorticoid use. CONCLUSION: The prevalence of morphometric vertebral deformities is high in CD and UC. Male sex, but neither disease activity, bone turnover markers, clinical risk factors, nor BMD predicted their presence. The determinants for having more than one vertebral deformity were age and glucocorticoid use. This implies that in addition to screening for low BMD, morphometric assessment of vertebral deformities is warranted in CD and UC.