Fracture risks for women in long-term care: high prevalence of calcaneal osteoporosis and hypovitaminosis D

STUDY OBJECTIVES: To determine the prevalence of osteoporosis as assessed by peripheral bone mineral density (BMD) in women living in a nursing home, to determine how many women with low BMD had received a diagnosis of osteoporosis, to assess the prevalence of vitamin D deficiency, and to seek reasons for vitamin D deficiency. DESIGN: Measurement of calcaneal BMD and serum 25-hydroxyvitamin D. SETTING: Skilled nursing facility. PATIENTS: Forty-nine women aged 68-100 years. MEASUREMENTS AND MAIN RESULTS: Bilateral calcaneal BMD was measured by dual-energy x-ray absorptiometry and serum 25-hydroxyvitamin D by radioimmunoassay. Medical records were reviewed to assess osteoporosis risk factors, previous documentation of osteoporosis or malabsorption, and supplemental vitamin D intake. Fifty-nine percent of the 39 women with calcaneal BMD measurements (95% confidence interval [CI] 44-74%) exhibited calcaneal osteoporosis (T score < -2.5). Sixty percent (95% CI 46-74%) had 25-hydroxyvitamin D levels of 20 ng/ml or less, which is associated with secondary hyperparathyroidism; only 4% of women had levels above 30 ng/ml, recently recommended as optimal. Vitamin D status was suboptimal even in most women taking multivitamins. Osteoporosis was documented in the records of 17% of 23 women with calcaneal osteoporosis. CONCLUSION: Osteoporosis was prevalent but poorly documented in women living in the nursing home. Peripheral BMD measurements have the potential to improve the recognition and management of osteoporosis in women in long-term care facilities. The high prevalence of vitamin D deficiency, even in those taking multivitamins, indicates that practical new approaches for vitamin D repletion in this population are urgently needed.     

Comparison of bone parameters by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography in Hutterite vs. non-Hutterite women aged 35-60 years

A previous report of elevated dual-energy X-ray absorptiometry (DXA) bone mineral density (BMD) Z scores suggests that Hutterite females might be significantly less likely to develop osteoporosis compared with other U.S. females. In the present study, we sought to determine if high Hutterite DXA BMD Z scores were elevated because of larger bone size. Hutterites reside in isolated, self-sufficient colonies with an emphasis on agricultural production, and girls enter a strenuous task rotation at age 15 years. We obtained cross-sectional bone measurements of the 66% distal tibia using peripheral quantitative computed tomography (pQCT) to compare bone size and geometry on 97 Hutterite and 30 non-Hutterite women, aged 35-60 years. Total body (TB) and lumbar bone mineral content (BMC), BMD, and bone area measurements by DXA were available on a subset of the study population. We identified no differences between groups in pQCT total bone area, cortical bone area, or cortical bone density. Larger bone area by DXA was apparent in Hutterites compared with non-Hutterites at the TB (least square means: 2038 +/- 8 cm2 vs. 1953 +/- 19 cm2, p < 0.05) and lumbar (least square means: 58 +/- 0.5 cm2 vs. 57 +/- 2 cm2, p < 0.01) sites. TB BMC adjusted for TB bone area was marginally higher in Hutterites compared with non-Hutterites (least square means: 2341 +/- 15 g vs. 2281 +/- 30 g, p = 0.08). Hutterites had marginally higher TB BMD Z scores when controlling for weight and age (least square means: 1.3 +/- 0.1 vs. 0.8 +/- 0.2, p = 0.07). Hutterites had higher lumbar BMC adjusted for lumbar bone area and weight (least square means: 65 +/- 1 g vs. 58 +/- 2 g, p < 0.01) and higher weight-and age-adjusted lumbar BMD Z scores (least square means: 1.1 +/- 0.1 vs. 0.1 +/- 0.4, p = 0.01). Our data indicate that a true advantage in trabecular bone density probably exists among Hutterite women aged 35-60 years. Hutterite women might be protected against age-related fractures because of their larger bone size and higher bone density at normally susceptible trabecular sites.     

Outcome in congenital stridor (laryngomalacia)

Twenty-one children who had been diagnosed as having laryngomalacia by direct laryngoscopy in infancy were reviewed 7 to 12 years later. The natural history of the disease is documented. A wide variation in the time of onset and duration of the stridor was found and there was a high incidence of feeding difficulties. A previously reported association with mental retardation or cerebral palsy is not confirmed. 4 out of the 21 children had early speech problems.     

Menkes's syndrome. Report of a patient treated from 21 days of age with parenteral copper

In an infant with Menkes's steely-hair syndrome, early treatment (from 21 days of age) with parenteral copper failed to halt the disease. In addition to urinary tract abnormalities, panlobular emphysema was present a finding not previously noted in the syndrome.     

Factor V deficiency in Philadelphia-positive chronic myelogenous leukemia

Factor V deficiency has been identified in 8 of 8 patients 7--20 yr of age, with Philadelphia-positive (Ph1+) chronic myelogenous leukemia (CML). In these 8 patients, factor V deficiency was not due to hepatic dysfunction, factor V inhibitors, or disseminated intravascular coagulation. In 3 patients, factor V activity rose 10%--12% (0.10--0.12 U/ml) after the infusion of 28--31 ml/kg body weight of fresh frozen plasma (FFP). The rise persisted less than 14 hr. The mean measured postinfusion rise in factor V was 18% of the expected rise calculated from the volume of FFP infused in the patients' plasma volume. In 4 patients, a small transient rise in factor V activity occurred after splenectomy or plateletpheresis. Factor V deficiency was completely corrected after a marked reduction in bone marrow cellularity in 2 patients with Ph1+ CML treated with extensive chemotherapy, total body irradiation, and bone marrow transplantation. Factor V deficiency was retrospectively observed in 6 of 20 patients, ages 20--80 yr, with Ph1+ CML and 3 of 6 patients with other myeloproliferative disorders. The factor V deficiency appears to be associated with the large myeloid- megakaryocytic cell mass characteristic of CML and other myeloproliferative disorders.     

Peripheral quantitative computed tomography in children and adolescents: the 2007 ISCD Pediatric Official Positions

Peripheral quantitative computed tomography (pQCT) has mainly been used as a research tool in children. To evaluate the clinical utility of pQCT and formulate recommendations for its use in children, the International Society of Clinical Densitometry (ISCD) convened a task force to review the literature and propose areas of consensus and future research. The types of pQCT technology available, the clinical application of pQCT for bone health assessment in children, the important elements to be included in a pQCT report, and quality control monitoring techniques were evaluated. The review revealed a lack of standardization of pQCT techniques, and a paucity of data regarding differences between pQCT manufacturers, models and software versions and their impact in pediatric assessment. Measurement sites varied across studies. Adequate reference data, a critical element for interpretation of pQCT results, were entirely lacking, although some comparative data on healthy children were available. The elements of the pQCT clinical report and quality control procedures are similar to those recommended for dual-energy X-ray absorptiometry. Future research is needed to establish evidence-based criteria for the selection of the measurement site, scan acquisition and analysis parameters, and outcome measures. Reference data that sufficiently characterize the normal range of variability in the population also need to be established.     

Vitamin K Treatment Reduces Undercarboxylated Osteocalcin but Does Not Alter Bone Turnover,Density, or Geometry in Healthy Postmenopausal North American Women

Low vitamin K status is associated with low BMD and increased fracture risk. Additionally, a specific menaquinone, menatetrenone (MK4), may reduce fracture risk. However, whether vitamin K plays a role in the skeletal health of North American women remains unclear. Moreover, various K vitamers (e.g., phylloquinone and MK4) may have differing skeletal effects. The objective of this study was to evaluate the impact of phylloquinone or MK4 treatment on markers of skeletal turnover and BMD in nonosteoporotic, postmenopausal, North American women. In this double‐blind, placebo‐controlled study, 381 postmenopausal women received phylloquinone (1 mg daily), MK4 (45 mg daily), or placebo for 12 mo. All participants received daily calcium and vitamin D₃ supplementation. Serum bone‐specific alkaline phosphatase (BSALP) and n‐telopeptide of type 1 collagen (NTX) were measured at baseline and 1, 3, 6, and 12 mo. Lumbar spine and proximal femur BMD and proximal femur geometry were measured by DXA at baseline and 6 and 12 mo. At baseline, the three treatment groups did not differ in demographics or study endpoints. Compliance with calcium, phylloquinone, and MK4 treatment was 93%, 93%, and 87%, respectively. Phylloquinone and MK4 treatment reduced serum undercarboxylated osteocalcin but did not alter BSALP or NTX. No effect of phylloquinone or MK4 on lumbar spine or proximal femur BMD or proximal femur geometric parameters was observed. This study does not support a role for vitamin K supplementation in osteoporosis prevention among healthy, postmenopausal, North American women receiving calcium and vitamin D supplementation.     

New universal precaution aspiration tray

A new tray has been designed for use during procedures involving needles and other sharp objects. The tray includes a foam adhesive pad, marked into 10 sections, into which the sharp objects can be placed point first. After the procedure, the objects can be safely withdrawn by their handles and then discarded. The tray has been used in more than 250 procedures.