Reproducibility of total and regional body composition using dual-energy X-ray absorptiometry in rheumatoid arthritis and ankylosing spondylitis.

Several studies have reported changes in body composition in rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Our study showed that body composition measurements obtained by absorptiometry were highly reproducible in patients suffering from these diseases. This study justifies the use of absorptiometry measurements in longitudinal studies in this population. PURPOSE: Our study aimed to assess the reproducibility of total and regional body composition in patients with rheumatoid arthritis (RA) and with ankylosing spondylitis (AS) and to compare them to healthy subjects. METHODS: The study enrolled 80 subjects including 32 healthy subjects, 31 RA patients, and 17 AS patients. Each subject had two scans in one day under the same standard conditions and none ate nor drunk before being repositioned on the table. The reproducibility was assessed through the coefficient of variation (CV), the least significant change (LSC), the intraclass correlation (ICC), and the smallest significant difference (SDD). RESULTS: Total body composition measurements obtained by dual-energy X-ray absorptiometry (DXA) were highly reproducible, and there was no statistically significant difference between reproducibility in healthy subjects, patients with RA, and patients with AS. For total body fat mass (FM), lean mass (LM), and bone mineral content (BMC) in the total population, CV values were 1.71%, 1.25%, and 1.74%, respectively; ICC values were 0.998, 0.996, and 0.993, respectively; LSC values were 4.88%, 3.7%, and 5.2%, respectively; and SDD values were ± 1.23 Kg, ± 1.47 Kg, and ± 126.0 g, respectively. For regional body FM, LM, and BMC in the total population, CV values in the arms were 8.46%, 4.17%, and 3.79%, respectively; in the legs 6.24%, 3.59%, and 2.04%, respectively, and in the trunk 5.02%, 2.92%, and 5.24%, respectively. CONCLUSION: Total body tissue mass, FM percentage, FM, LM, and BMC measurements obtained by DXA are highly reproducible in RA and AS.

Vertebral fractures and abdominal aortic calcification in postmenopausal women. A cohort study.

INTRODUCTION: Vertebral fracture assessment (VFA) imaging with a bone densitometer can simultaneously detect prevalent vertebral fractures (VFs) and abdominal aortic calcification (AAC). OBJECTIVE: To study the relation between the prevalence of VFs using VFA in asymptomatic women and the prevalence and severity of AAC. DESIGN: This is a cross-sectional study. SETTINGS: Subjects were recruited in a third care center from asymptomatic women selected from the general population. PARTICIPANTS: We enrolled 908 post-menopausal women with a mean age of 60.9 years ± 7.7 (50 to 91) with no prior known diagnosis of osteoporosis or taking medication interfering with bone metabolism. PRIMARY AND SECONDARY OUTCOME MEASURES: Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. VFA images were scored for AAC using a validated 24 point scale. RESULTS: VFA images showed that 179 of the participants (19.7%) had at least one grade 2/3 VF, 81% did not have any detectable AAC whereas the prevalence of significant atherosclerotic burden, defined as AAC score of 5 or higher, was 12%. The group of women with 2/3 VFs had a statistically significant higher AAC score and higher proportion of subjects with extended AAC, and lower weight, height, and lumbar spine and hip BMD and T-scores than those without VFA-identified VFs. Multiple regression analysis showed that the presence of grade 2/3 VFs was significantly associated with age, BMI, history of peripheral fracture, AAC score ≥ 5 and densitometric osteoporosis. CONCLUSION: In post-menopausal women, extended AAC is independently associated with prevalent VFs regardless of age, BMI, history of fractures, and BMD.

Systematic vertebral fracture assessment in asymptomatic postmenopausal women.

INTRODUCTION: Recognition of vertebral fractures (VFs) changes the patient's diagnostic classification, estimation of fracture risk, and threshold for pharmacological intervention. Vertebral fracture assessment (VFA) enables the detection of VFs in the same session as bone mineral density (BMD) testing. OBJECTIVE: To study prevalence and risk factors of VFs using VFA in asymptomatic women and measure its effect on treatment recommendations. METHODS: We enrolled 908 postmenopausal women (mean age, weight and BMI of 60.9 ± 7.7 (50-91) years, 73.2 ± 13.2 (35-150) kg and 29.8 ± 5.3 (14.5-50.8) kg/m(2), respectively. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. RESULTS: VFs were identified in 382 patients (42.0%): 203 (22.3%) had grade 1 and 179 (19.7%) had grade 2 or 3. The prevalence of VFA-detected fractures globally increased significantly with age and as BMI and BMD declined. A fracture was identified on VFA in 63 (28.3%) women with normal BMD (8.5% had grade 2/3 VFs) and in 145 (38.5%) with osteopenia (15.7% had grade 2/3 VFs). Stepwise regression analysis showed that presence of VFs was independently related to age, BMI, number of parity, history of peripheral fracture and lumbar spine BMD. CONCLUSION: A high proportion of women with asymptomatic VFs would not receive treatment if screening were based only on BMD evaluation. Our results support the recommendation to enlarge the indications of VFA in the presence of risk factors such as age over 60, multiparity, history of peripheral traumatic fractures and low BMI.

Vertebral fracture assessment in asymptomatic men and its impact on management.

INTRODUCTION: Recognition of vertebral fractures (VFs) change the patient's diagnostic classification, estimation of fracture risk, and threshold for pharmacological intervention. Vertebral fracture assessment (VFA) enables the detection of VFs in the same session as bone mineral density (BMD) testing. OBJECTIVE: To study prevalence and risk factors of VFs using VFA in asymptomatic men and measure its impact on patients' management. METHODS: We enrolled 791 men aged between 45 and 89 (mean age, weight and BMI of 62.4±8.6) (45 to 89) years, 74.9±12.7 (40 to 163) and 26.3±4.0 (16.6 to 43.8) kg/m(2), respectively. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. RESULTS: VFs were identified in 318 (40.3%): 206 (26.0%) had grade 1 and 112 (14.2%) had grade 2 or 3. As would be expected, the prevalence of VFA-detected fractures globally increased significantly with age and as BMI and BMD declined. A fracture was identified on VFA in 85 (32.4%) of men with normal BMD (6.9% had grade 2/3 VFs) and in 144 (35.8%) with osteopenia (11.7% had grade 2/3 VFs). Stepwise regression analysis showed that presence of VFs was independently related to the osteoporotic status (OR=4.761, 95%CI [2.956-7.668]; p<0.0001) and current smoking (OR=1.717, 95%CI [1.268-2.323]; p=0.002). CONCLUSION: Our results support the recommendation to enlarge the indications of VFA to all the men referred for DXA measurement.

Prevalence and risk factors of osteoporosis and vertebral fractures in patients with ankylosing spondylitis.

UNLABELLED: Ankylosing spondylitis (AS) is characterized by inflammation of the entheses and paravertebral structures, leading in time to bone formation at those sites. As well, vertebral bone loss is also a recognized feature of AS Objective: To calculate the prevalence and risk factors of osteoporosis and vertebral fractures in patients with AS. METHODS: Eighty patients with AS were enrolled in the study. Clinical, biological and radiological status was assessed by the Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), ESR and C-reactive protein (CRP), Bath AS Radiology Index (BASRI) and modified stoke AS spine score (mSASSS). BMD of the hip and spine was measured and vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry by VFA (fracture vertebral assessment). RESULTS: The years+/-11.8. The mean BMI was 22.8 kg/m(2)+/-4.1 and the mean disease duration was 10.8 years+/-6.6. Prevalence of osteoporosis was 25%. 18.8% of patients had a vertebral fracture (grades 2 and 3). Factors associated with osteoporosis were low weight and BMI and longer disease duration, higher ESR, CRP, BASFI and BASDAI. Vertebral fractures were associated with advanced age, longer disease duration, higher BASFI, BASRI and mSASSS and reduced BMD and T-score at the hip site, presence of osteoporosis at any site. Multiple logistic regression analysis (Table 4) revealed that parameters significantly associated with osteoporosis were BASDAI (OR=1.05, 95% confidence interval [CI]: 1.03-1.09); disease duration (OR=1.13, 95%CI: 1.03-1.25); and BMI (OR=0.82, 95%CI: 0.69-0.93). The presence of VFs (grades 2 and 3) were independently associated with disease duration (OR=1.50, 95%CI: 1.07-2.10); and mSASSS (OR=1.17, 95%CI: 1.05-1.30). CONCLUSION: Osteoporosis is common in patients with AS and seems to be related to disease activity while vertebral fractures appear to be related to the duration and structural severity of the disease rather than BMD.

Vertebral fracture assessment in Moroccan women: prevalence and risk factors.

INTRODUCTION: Vertebral fracture assessment (VFA) is a fast, low-radiation technique which produces images that are of sufficient quality to be used to diagnose the presence of vertebral deformity consistent with fracture. OBJECTIVE: To study prevalence and risk factors of vertebral fractures using VFA in asymptomatic Moroccan women. METHODS: The study cohort consists of a population of 328 consecutive women aged over 50 (mean age, weight and BMI of 65+/-6.5 (50-84) years, 72.0+/-12.8 (42-125) and 29.4+/-5.0 (17.1-45.8)kg/m(2), respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. Vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. RESULTS: 68% of vertebrae from T4-L4 and 75% from T8-L4 were adequately visualized on VFA. Vertebral fractures (grades 2 or 3) were detected in 25.6% (84/328) of these women. Thirty-two of women with VFA-identified fracture (38.0%) had only a single vertebral fracture, while the other 61.9% had two or more. Fractures were most common in the mid-thoracic spine and at the thoraco-lumbar junction. As would be expected, the prevalence of VFA-detected fractures increased with age and as BMD declined. Stepwise regression analysis showed that presence of vertebral fracture was mainly related to the spine osteoporotic status, age older than 65, history of peripheral fracture and more than six parities. CONCLUSION: Vertebral fractures are common in asymptomatic Moroccan women and are related to age, low BMD, history of fracture and multiparity.

Bone mineral density of the spine and femur in a group of healthy Moroccan men.

BACKGROUND: Bone mineral density (BMD) measurements using dual-energy X-rays absorptiometry (DXA) are widely used to diagnose osteoporosis and to assess its severity. Previous studies show the necessity to establish reference data for bone mass measurements for each particular population. Such data are lacking for the male Moroccan population. AIM: To establish reference values for the healthy Moroccan male population and to compare them with those for Caucasian and Arab males, and to study the impact of different curves implemented in the DXA system on the diagnosis of osteoporosis. METHODS: A cross-sectional study of 592 Moroccan men, recruited from the area of Rabat, the capital of Morocco, aged between 20 and 79 years was carried to establish reference values of bone mineral density. Measurements were taken at the lumbar spine and proximal femurs using DXA (Lunar Prodigy Vision, GE). The data were compared with published normative taken by US, European, Iranian, Lebanese, and Saudi men over six decades of age. Impact on osteoporosis diagnosis according to the WHO criteria using the personalized curve and US (NHANES), European and Middle-East reference curves (as implemented in the Lunar densitometers) was studied. RESULTS: Our results showed that the Moroccan men showed the expected decline in BMD at both sites with age after peaking at 20-29 years age group. Every anatomical region has a different rate of bone loss: lumbar spine (0.3% per year) femoral neck (0.6%), trochanter (0.3%), and total hip (0.4%). The lumbar spine and femoral subregions BMD exhibited increases from 0.3 to 0.5% per kilogram of body weight. In the spine, the US/European Lunar reference values classified a larger proportion of men as osteoporotic (18.1% vs. 7.4%) while using the Arabic Lunar reference values, only 7.8% were classified as osteoporotic. However, using Arabic curve for the femurs resulted in underdiagnosis of osteoporosis (1.8% vs. 6.0%), whereas the US/European Lunar reference values classified men as osteoporotic in 3.9% and 5.3% respectively. DISCUSSION: In comparison with the other Countries, the spine BMD of Moroccan men were slightly lower than Iranian's, Europeans and Brazilians but higher than the Saudi and Lebanese males. We found BMD values taken at the lumbar spine to be around 4% lower than European values between ages 50 and 59 years, and 10% lower for older subjects. These values were 4-6% higher than Saudis/Lebanese values between ages 20-39. For older subjects, Moroccan values were more than 10% higher than Saudis and almost similar to Lebanese. Femoral neck BMD values were 8% higher in young adults (age 20-39 years) to US/Saudis/Lebanese values, but about 10% lower in ages over 60 to US values whereas it was similar to Saudis and Lebanese values. CONCLUSION: Our study emphasises the importance of using population-specific reference values for BMD measurements to avoid over or underdiagnosis of osteoporosis.

Performance of calcaneus quantitative ultrasound and dual-energy X-ray absorptiometry in the discrimination of prevalent asymptomatic osteoporotic fractures in postmenopausal women.

Due to its low cost, portability, and nonionizing radiation, quantitative ultrasound (QUS) of the heel is an alternative to the measurement with dual X-ray absorptiometry (DXA) in the evaluation of bone status. The objective of the study is to compare in asymptomatic postmenopausal women the ability of QUS and DXA to discriminate between those with and without prevalent vertebral fractures (VFs). The study cohort consists of a population of 295 postmenopausal women aged between 60 and 84 (mean age, weight and BMI of 66.3 years, 72.0 kg and 29.4 kg/m(2), respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. All women had a calcaneous QUS examination. The mean age of the women in our sample was 66.3 (+/-5.3) years, ranging from 60 to 84 years. Eighty-seven (29.3%) women had VFs Genant grade 2 and 3. Patients with VFs had an age and a number of years of menopause higher to those without VFs, but showed lower height, weight, and BMI. All densitometric and ultrasonometric measurements were significantly reduced in women with VFs. The intercorrelations of BMD at different sites were high, and the correlations of BUA with BMD were lower. BUA correlated weakly with total hip BMD (r = 0.36), lumbar spine BMD (r = 0.32), and much less with femur BMD (r = 0.30); all correlations were significant (P < 0.01). Analysis of the AUC for the ROC curves showed lumbar spine T-score below -2.5 to provide consistently the highest AUC (0.64). Age-adjusted ORs after correction for confounding variables (years of menopause, weight, height, and BMI) for QUS and BMD measurements showed that only lumbar spine T-score below -2.5 could predict significantly the presence of VFs (OR, 1.94; 95%CI, 1.02-3.41). Lumbar spine BMD (and not QUS) was able to discriminate asymptomatic postmenopausal women with prevalent VFs from women without VFs and independently contributed to determining the association with fracture. The combination of QUS and BMD did not improve the diagnostic ability of either individual technique.

Discordance between hip and spine bone mineral density measurement using DXA: prevalence and risk factors.

BACKGROUND: Diagnostic discordance for osteoporosis is the presence of different categories of T-scores in 2 skeletal sites of an individual patient, falling into 2 different diagnostic categories identified by the World Health Organization classification system. OBJECTIVES: To evaluate the prevalence and risk factors for T-score discordance between spine and total hip measurement sites. METHODS: Demographic data, anthropometric measurements, and risk factors for osteoporosis were derived from a database of 3479 patients referred to a community-based outpatient osteoporosis testing center. Dual-energy x-ray absorptiometry (DXA) was performed on L1-L4 lumbar spine and total hips for all cases. Minor discordance was defined as present when the difference between 2 sites was no more than 1 World Health Organization diagnostic class. Major discordance was present when 1 site is osteoporotic and the other is normal. Subjects with incomplete data were excluded. RESULTS: In 3479 participants (2871 women; mean age, 55.7 +/- 11.9 years), concordance of T-scores, minor discordance, and major discordance were seen in 54, 42, and 4%, respectively. In multivariate logistic regression analysis, age, menopause, and obesity were identified as risk factors against T-score discordance. CONCLUSION: Densitometrists and clinicians should expect that at least 4 of every 10 patients tested by DXA to demonstrate T-score discordance between spine and total hip measurement sites. T-score discordance can occur for a variety of reasons related to physiologic and pathologic patient factors as well as the performance or analysis of DXA itself.

Prevalence and risk factors of osteoporosis in patients with Parkinson's disease.

Parkinson's disease (PD) is the most common cause of disability in the elderly. It is currently recognized as a cause of secondary osteoporosis. To evaluate the prevalence of osteoporosis in PD and detect its risk factors, 52 patients with PD (36 men/16 women) and 52 controls paired for age and sex were recruited. Clinical data including demography, disease duration and disease severity were collected. All subjects had bone mineral density (BMD) measured by dual energy X-ray absorptiometry, dorsal and lumbar spine X-ray, and biological exams (osteocalcin, CTX, parathormon). The mean age of the patients was 60.0 +/- 9.25 years [30-77], and the mean disease duration was 4.9 +/- 4.5 years [0.2-17]. Nine patients (17.3%) were osteoporotic and 28 (53.8%) osteopenic. BMD at the lumbar spine and the hip was lower among patients than controls (spine: 1.031 vs. 1.175 g/cm(2); P < 0.001; hip: 0.968 vs. 1.054; P = 0.02). PD patients with low BMD presented a more severe disease and an insufficient sun exposure and calcium intake. There was a positive statistically significant correlation between patients BMD and body mass index and negative correlation with age, severity of PD, and osteocalcin levels. The prevalence of osteoporosis/osteopenia is high in PD patients and seems related to the severity of the disease, an insufficient sun exposure and calcium intake. This osteoporosis constitutes with falls the major risk factors of fracture in PD patients.

Drug-induced lupus-like syndrome in ankylosing spondylitis treated with infliximab.

Specific antagonists of tumour necrosis factor (TNF-alpha) have rapidly gained popularity for the treatment of rheumatoid arthritis and ankylosing spondylitis (AS). Reported side effects from these agents include drug-induced autoimmune disorders. The monoclonal antibody against TNF-alpha, infliximab, has been associated with induction of systemic lupus erythematosus (SLE) in only one patient with AS in the literature. However, there have been no published reports of drug induced lupus-like syndrome (LLS) with positive anti-histone antibodies. We describe a 59-year-old woman with a 12-year history of refractory axial AS who developed signs and symptoms of LLS during treatment with infliximb with positive antinuclear and anti-histone antibodies. On diagnosis of LLS, infliximab was discontinued and the LLS-related symptoms promptly resolved.

Bone turnover and hormonal perturbations in patients with fibromyalgia.

OBJECTIVE: Studies of bone turnover in fibromyalgia (FM) have, to date, shown conflicting results. Although most patients with FM are women, only a few investigations have paid attention to the changes of sex hormones in FM. Moreover, FM is often viewed as a stress related disorder, and abnormalities of the hypothalamic-pituitary-adrenal (HPA) axis have been found in FM. The aim of the study was to assess bone turnover using serum osteocalcin and CTx in patients with FM and study correlation between bone turnover parameters and parathormon and hormones of the HPA axis. METHODS: A total of 81 subjects participated in this study: 41 healthy volunteers and 40 patients with FM. Serum osteocalcin, crosslaps (C-telopeptide: CTx), parathyroid hormone (PTH), testosterone, estrogen, prolactin, FSH, and LH were measured. The mean age of the study population was 49.5 (7.6) years (32-69) and the mean disease duration was 8.1 (12.0) years (4.5-30.7). RESULTS: No difference between patients and controls were observed in serum calcium, phosphorus, creatinine, albumin, osteocalcin, testosterone, and urinary calcium. Patients had lower serum levels of CTx, estrogen, PTH and prolactin than controls and higher serum levels of LH and FSH with a significant statistical difference. No significant statistical correlation was observed between intensity of pain and fatigue and bone turnover parameters and PTH or hormones of the HPA axis. CONCLUSION: Our study showed that patients with FM had low bone resorption and normal bone formation compared to a control group. This was not related to several hormonal perturbations observed in these patients and may reflect functional impairment as suggested in previous studies.

Reproducibility of bone mineral density measurements using dual X-ray absorptiometry in daily clinical practice.

Bone mineral density (BMD) measurements are frequently performed repeatedly for each patient. Subsequent BMD measurements allow reproducibility to be assessed. Previous studies have suggested that reproducibility may be influenced by age and clinical status. The purpose of the study was to examine the reproducibility of BMD by dual energy X-ray absorptiometry (DXA) and to investigate the practical value of different measures of reproducibility in three distinct groups of subjects: healthy young volunteers, postmenopausal women and patients with chronic rheumatic diseases. Two hundred twenty-two subjects underwent two subsequent BMD measurements of the spine and hip. There were 60 young healthy subjects, 102 postmenopausal women and 60 patients with chronic rheumatic diseases (33 rheumatoid arthritis, 10 ankylosing spondylitis and 10 other systemic diseases). Forty-five patients (75%) among the third group were receiving corticosteroids. Reproducibility was expressed as the smallest detectable difference (SDD), coefficient of variation (CV), least significant change (LSC) and intraclass correlation coefficient (ICC). Sources of variation were investigated by linear regression analysis. The median interval between measurements was 0 days (range 0-7). The mean difference (SD) between the measurements (g/cm2) was -0.0001 (+/-0.003) and -0.0004 (+/-0.002) at L1-L4 and the total hip, respectively. At L1-L4 and the total hip, SDD (g/cm2) was +/-0.04 and +/-0.02, CV (%) was 2.02 and 1.29, and LSC (%) 5.60 and 3.56, respectively. The ICC at the spine and hip was 0.99 and 0.99, respectively. Only a minimal difference existed between the groups. Reproducibility in the three groups studied was good. In a repeated DXA scan, a BMD change, the least significant change (LSC) or the SDD should be regarded as significant. Use of the SDD is preferable to use of the CV and LSC because of its independence from BMD and its expression in absolute units. Expressed as SDD, a BMD change of at least +/-0.04 g/cm2 at L1-L4 and +/-0.02 g/cm2 at the total hip should be considered significant. This reproducibility seems independent from age and clinical status and improved in the hips by measuring the dual femur.

[Isolated tuberculosis of the sternum. Two cases]. / Tuberculose sternale isolée. Deux observations.

INTRODUCTION: Among the extra-pulmonary localizations, isolated tuberculosis of the sternum is rare and difficult to diagnose. OBSERVATIONS: A 30 year-old man presented with tumefaction of the sternum that had developed over the past two months and a 52 year-old woman had developed a painful tumefaction of the sternum over the past 4 months. In both cases, the histopathological examination of a biopsy confirmed the diagnosis of tuberculosis. Anti-bacterial therapy permitted the favourable progression of the disease. DISCUSSION: Such diagnosis is rare. Contamination can occur through contiguity, which was not manifest in either of the two cases. Confrontation between the histological and/or bacteriological samples is required.