A 246-km continuous running race causes significant changes in bone metabolism.

BACKGROUND: Regular physical exercise exerts a favorable effect on the skeleton. However, excessive physical exercise may have detrimental effects. A low bone mineral density (BMD) has been registered in highly trained runners. The aim of the present study was to evaluate potential effects of the Spartathlon, an annual ultramarathon race of 246 km, on bone metabolism. METHODS: Venous blood samples were taken before and within 15 min after the end of the race as well as three days after the start of the race. The following variables of bone metabolism were studied: osteocalcin (Oc), cross-linked-C-telopeptide of type I collagen (CTX), osteoprotegerin (OPG), and its ligand, receptor activator of nuclear factor kappaB ligand (RANKL). RESULTS: Blood samples were taken from 18 runners (16 men and 2 women) at the three time points. The median time taken by the runners to complete the race was 32 h and 52 min. Serum levels of CTX were significantly increased immediately after the race as well as three days after the start of the race compared with the time prior to the race. Oc was transiently suppressed after the race. Serum levels of RANKL and OPG were increased three days after the start of the race compared to the time before the start of the race. CONCLUSIONS: This study showed that an ultra-distance run of nearly 250 km induced changes in RANK/RANKL/OPG interaction, which suggests a transient uncoupling of bone metabolism, increased bone resorption, and suppressed bone formation.

Zoledronic acid prevents cancer treatment-induced bone loss in premenopausal women receiving adjuvant endocrine therapy for hormone-responsive breast cancer: a report from the Austrian Breast and Colorectal Cancer Study Group.

PURPOSE: Adjuvant therapy for breast cancer can be associated with decreased bone mineral density (BMD) that may lead to skeletal morbidity. This study examined whether zoledronic acid can prevent bone loss associated with adjuvant endocrine therapy in premenopausal patients. PATIENTS AND METHODS: This study is a randomized, open-label, phase III, four-arm trial comparing tamoxifen (20 mg/d orally) and goserelin (3.6 mg every 28 days subcutaneously) +/- zoledronic acid (4 mg intravenously every 6 months) versus anastrozole (1 mg/d orally) and goserelin +/- zoledronic acid for 3 years in premenopausal women with hormone-responsive breast cancer. In a BMD subprotocol at three trial centers, patients underwent serial BMD measurements at 0, 6, 12, 24, and 36 months. RESULTS: Four hundred one patients were included in the BMD subprotocol. Endocrine treatment without zoledronic acid led to significant (P < .001) overall bone loss after 3 years of treatment (BMD, -14.4% after 36 months; mean T score reduction, -1.4). Overall bone loss was significantly more severe in patients receiving anastrozole/goserelin (BMD, -17.3%; mean T score reduction, -2.6) compared with patients receiving tamoxifen/goserelin (BMD, -11.6%; mean T score reduction, -1.1). In contrast, BMD remained stable in zoledronic acid-treated patients (P < .0001 compared with endocrine therapy alone). No interactions with age or other risk factors were noted. CONCLUSION: Endocrine therapy caused significant bone loss that increased with treatment duration in premenopausal women with breast cancer. Zoledronic acid 4 mg every 6 months effectively inhibited bone loss. Regular BMD measurements and initiation of concomitant bisphosphonate therapy on evidence of bone loss should be considered for patients undergoing endocrine therapy.

Limited diagnostic agreement of quantitative sonography of the radius and phalanges with dual-energy x-ray absorptiometry of the spine, femur, and radius for diagnosis of osteoporosis.

OBJECTIVE: The aim of our study was to evaluate the diagnostic agreement of quantitative sonography of the radius and proximal phalanx and dual-energy X-ray absorptiometry (DXA) of the radius, lumbar spine, and femoral neck for the detection of osteoporosis. MATERIALS AND METHODS: In 95 women (mean age, 53 +/- 13 years) and 26 men (mean age, 53 +/- 13 years), DXA measurements of the lumbar spine (posterior-anterior, L1-L4) and the femoral neck, as well as quantitative sonography of the radius and proximal phalanx of the third finger were obtained. The percentage of patients below a given threshold was calculated for each imaging technique. A T score of less than -2.5 indicated presence of osteoporosis. Diagnostic agreement in identifying individuals with osteoporosis was assessed using kappa scores. RESULTS: Between 14% and 22% of the patients were classified as osteoporotic after DXA of the various regions of interest of the radius, 31% after DXA of the spine, 43% after DXA of the femoral neck, 32% after quantitative sonography of the distal radius, and 34% after quantitative sonography of the phalanx of the third finger. Correlation coefficients between T values for quantitative sonography and those for DXA varied between not significant and 0.54 at the different regions. Kappa analysis showed the diagnostic agreement among quantitative sonography and DXA to be fair to moderate (kappa = 0.38-0.48). The highest agreement was between quantitative sonography of the proximal phalanx of the third finger and DXA of the total radius (kappa 0.48; p < 0.05). CONCLUSION: Considerable diagnostic disagreement exists between quantitative sonography and DXA of the forearm, as is true for most quantitative techniques in the assessment of skeletal status. The lack of correlation makes quantitative sonography impractical for routine diagnostic use but might characterize different parameters related to bone quality.

Comparative assessment of bone mineral measurements obtained by use of dual-energy x-ray absorptiometry, peripheral quantitative computed tomography, and chemical-physical analyses in femurs of juvenile and adult dogs.

OBJECTIVE: To compare bone mineral measurements obtained by use of dual-energy x-ray absorptiometry (DEXA), peripheral quantitative computed tomography (pQCT), and chemical-physical analyses and determine effects of age and femur size on values obtained for the various techniques. SAMPLE POPULATION: Femurs obtained from 15 juvenile and 15 adult large-breed dogs. PROCEDURE: n each femur, 7 regions of interest were examined by use of DEXA to measure the bone mineral content (BMC) and bone mineral density (BMD), and 5 were examined by use of pQCT to measure BMD. Among these, 1 region was examined by both noninvasive methods and an invasive method. Volume of the femur was determined by water displacement. Volumetric bone density (VBD) was calculated. Calcium (Ca), phosphorus (P), total Ca, and total P contents were determined. RESULTS: DEXA- and pQCT-derived results revealed that all values increased with age in juvenile dogs. In adults, VBD and pQCT-derived BMD decreased significantly and DEXA-derived BMD increased with increasing femur length. The pQCT-derived BMD correlated well with VBD and Ca content, whereas DEXA-derived BMC was strongly correlated with Ca content. In juveniles, values correlated regardless of the technique used, whereas in adult dogs, DEXA-derived BMD did not correlate with pQCT-derived BMD, Ca concentration, or VBD unless data were adjusted on the basis of femur length. CONCLUSIONS AND CLINICAL RELEVANCE: DEXA-derived BMD adjusted for femur length yields approximately the same percentage variability in VBD as for pQCT-derived BMD. However, pQCT-derived BMD is still more sensitive for determining variability BMD in Ca concentration, compared with DEXA-derived BMD adjusted for femur length.

Chondrosarcoma of the hand: is a wide surgical resection necessary?

Chondrosarcomas of the hand are rare and generally treated with surgical resection. Thirteen patients with Grade 1 chondrosarcoma of the small bones of the hand were followed up for a mean of 99.8 months (range, 26-293 months). In eight patients (Group 1) curettage and reconstruction with cancellous bone was done and in five patients (Group 2) a wide resection was done. No patient experienced relapse in Group 2. In Group 1 one patient had a local relapse 18 months after intralesional resection. Using the Musculoskeletal Tumor Society score for evaluation, the clinical results showed an average of 98% and 95% of the normal function in Groups 1 and 2, respectively. None of the patients had evidence of systemic spread of the disease. With a relapse rate of 12.5% and no distant metastases after curettage, intralesional resection is the preferred method of treatment in Grade 1 chondrosarcoma of the hand, allowing the patient to avoid amputation and major loss of function.

'The Closer'-percutaneous vascular suture device: evaluation of safety and performance in neuroangiography.

OBJECTIVE: To evaluate the use of the suture mediated vascular closure device concerning practicability and safety in clinical angiography practice. MATERIAL AND METHODS: One hundred and seventeen patients (59 female, 58 male, mean age 40.9+/-13.4) underwent percutaneous closure of common femoral arterial puncture sites following diagnostic neuroangiography using the suture device 'the Closer' (Perclose Inc., Redwood City, CA, USA). Primary success, early problems (within 24 h) and late complications were evaluated. Complications were graded as minor and severe with or without need of surgical intervention and categorized by type. Parameters such as age, gender, sheath size and number of previous arterial punctures were evaluated with respect to complications. RESULTS: Percutaneous closure was primary successful in 85% (100/117). The overall complication rate was 32% (28% mild n=35, 4% severe n=6, which needed surgical intervention). All but one problem occurred within the first 24 h after the suture. Additional manual compression was necessary in 32 cases (25%). There was no significant difference in age and gender between the groups with and without complications. Sheath size was significantly larger (P<0.01) and numbers of preceeding angiograms were significantly higher (P<0.01) in the complications group compared with uncomplicated cases. CONCLUSION: The evaluated percutaneous vascular suture device is useful in clinical practice but limitations concerning patient selection seem to emerge in order to avoid complications.

Automated vessel edge detection in velocity-encoded cine-MR (VEC-MR) flow measurements: a retrospective evaluation in critically ill patients.

OBJECTIVE: To assess feasibility of automated edge detection in magnetic resonance (MR) flow calculations in a clinical setting with critically ill patients. MATERIAL AND METHODS: Velocity encoded cine-MR (VEC-MR) flow measurements cross-sectional area (CSA), mean spatial velocity (MSV), instantaneous flow (IF), flow (F), 0.5 T Philips, TR 800-800, TE=8 ms, 30 degrees flip angle, FOV 280 mm, 128 x 256 matrix, temporal resolution 16 time frames/RR, VENC=120 cm/s) were obtained in 20 major thoracic human vessels (ascending aorta, main, right and left pulmonary artery-AAO, MPA, RPA, LPA) of five patients, suffering from severe chronic thromboembolic pulmonary hypertension (CTEPH). Flow maps were evaluated by two independent observers using conventional manual edge detection (INTER m/m). Flow calculations were performed by one observer using both, manual and automated edge detection (INTRA m/a), by a second observer using automated edge detection two times (INTRA a/a) and by two independent observers using automated edge detection (INTER a/a). Evaluation time was measured. Linear regression analysis and Student's t-test were performed. RESULTS: Overall regression coefficients (r2) for INTER m/m, INTRA m/a, INTER a/a and INTRA a/a, respectively, were as follows: CSA, 0.91, 0.91, 0.96, 0.98; MSV, 0.97, 0.99, 0.99, 0.99; IF, 0.98, 0.99, 0.99, 0.99; F, 0.98, 0.99, 0.99, 0.99. Manual CSA values differed significantly from automated data in MPA (P=0.01), RPA (P=0.0008) and LPA (P=0.02). No difference was found for the other assessed parameters of the pulmonary circulation. Average evaluation time per vessel was 20.2+/-2.6 min for manual and 2.1+/-0.7 min for automated edge detection (P<0.00001). CONCLUSION: The software program used provided reproducible data, lead to a 90% reduction in evaluation and calculation time and, therefore, might excel the utilization of VEC-MR flow measurements. Despite variations in the evaluation of the pulmonary circulation CSAs, flow assessment is feasible in critically ill patients.

Quantification and clinical relevance of head motion during computed tomography.

OBJECTIVE: To quantify the 3-dimensional translation and rotation components of head motion during computed tomography and to analyze the influence of such motion on perceptible artifacts and distortion of volume image data sets. METHODS: Using high-precision optoelectronic motion-capture technology, changes in patient head position during axial CT scanning were registered in 20 cases and 2 phantoms with a spatial relative resolution better than 0.003 cm. Statistical analysis was performed on a base of 6-dimensional measurement-vectors, each with 3 translation and 3 rotation values. Because of the recording frequency of the tracking system, more than 80000 values were included in a statistical analysis. RESULTS: All 20 patients had head motion during the CT scanning, with only 4 of 20 patients showing perceptible motion artifacts. The frequency, the extent, and the direction of the movements did not correlate with either the observations made by the radiologic staff or with the patient's subjective estimation of comfort. Translation movements of the head during CT accounted for a maximum of 0.5 cm and rotations of more than 2 degrees without perceptible motion artifacts. The extent of positional changes of the head was found to correlate with the duration of scanning (Pearson's correlation coefficient: 0.647 for translation shifts, 0.453 for rotation shifts). The mean direction of head motion could be characterized predominantly as a rotation around the longitudinal axis of the body (xy plane) at a significance level of 0.01. CONCLUSION: Computed tomography evaluations of the head performed without rigid fixation suffer a spatial distortion of the volume image data sets, caused by interimage motion. The absence of motion artifacts is not correlated with the absence of motion.

Pathogenesis of bone loss in heart transplant candidates and recipients.

BACKGROUND: Heart transplantation (HTX) is associated with decreased bone mineral density and changes in bone metabolism. We conducted this study to evaluate the pathophysiology of bone metabolism in HTX candidates and recipients. METHODS: Thirty-six HTX recipients were compared with 36 HTX candidates concerning biochemical parameters of bone metabolism and bone mineral density. RESULTS: Osteocalcin, bone-specific alkaline phosphatase, cross-linked-N-telopeptide of type I collagen, estradiol, serum creatinine, and blood urea nitrogen concentrations were significantly higher, whereas the calcium-creatinine ratio, thyrotropin, thyroxine, and bone mineral density were significantly lower in HTX recipients than in HTX candidates. Compared with a control group, HTX candidates had decreased renal function and increased bone resorption, whereas HTX recipients additionally had increased alkaline phosphatase and osteocalcin levels. In HTX recipients, we found positive correlations between creatinine clearance and bone mineral density; daily and cumulative cortisone doses were not associated with bone mineral density. CONCLUSIONS: In HTX candidates, disturbances in bone metabolism with increased bone resorption may be caused partly by existing low-grade renal insufficiency, regular intake of loop diuretics, and restriction of mobility. In HTX recipients, immunosuppressive therapy-glucocorticoids and cyclosporine-seem to be responsible for changes in bone metabolism.

Bone homogeneity factor: an advanced tool for the assessment of osteoporotic bone structure in high-resolution magnetic resonance images.

RATIONALE AND OBJECTIVES: Osteoporosis is characterized by low bone mass and inferior structural competence. In this study we introduce the bone homogeneity factor (BHF) as a quantitative measurement of bone structure, which could be equally important as bone mineral density. METHODS: BHF represents an advanced texture analysis tool based on the spatial autocorrelation function calculated in 9 different directions. These calculations were performed on high-resolution magnetic resonance images of the calcaneus at 3.0 T and compared with dual-energy x-ray absorptiometry measurements of the femoral neck. RESULTS: The quality and resolution of the high-resolution magnetic resonance images is sufficient for reliably calculating BHF. The mean BHF of the control group (n = 5, mean BHF = 525,0) with normal bone is significantly (P = 0.009, Mann-Whitney U test) higher than in the osteoporotic group (n = 7, mean BHF = 137,8). The BHF correlates with the DXA measurements of the femoral neck (correlation coefficient = 0.75). CONCLUSIONS: By calculating the BHF, it was possible to distinguish between osteoporotic and nonosteoporotic bone structure. Hence, BHF could be a possible candidate for noninvasive assessment of osteoporotic bone structure giving additional information to routinely used bone mineral densitometry.

Suspected pulmonary embolism: enhancement of pulmonary arteries at deep-inspiration CT angiography--influence of patent foramen ovale and atrial-septal defect.

PURPOSE: To investigate if abnormal early contrast enhancement of the aorta and decreased attenuation of pulmonary arteries at deep-inspiration spiral computed tomographic (CT) angiography might be caused by a patent foramen ovale (PFO). MATERIALS AND METHODS: Two hundred forty-four spiral CT angiographic images of the pulmonary arteries obtained during deep inspiration in patients suspected of having pulmonary embolism (PE) were reviewed for evidence of abnormal early enhancement of the aorta. In 45 patients, enhancement of the ascending aorta was equal to or more than that of the pulmonary arteries. Nonenhanced or contrast material-enhanced echocardiography was performed in 39 of these cases. All CT images with abnormal enhancement patterns were graded for contrast quality with respect to sufficient enhancement of pulmonary arteries (four grades) at three anatomic levels: right and left main and lobar and segmental branches. In addition, all spiral CT angiographic images were evaluated concerning the diagnosis of PE and the grouping of central (main pulmonary artery to proximal lobar arteries) and peripheral (beyond proximal lobar branches) locations of emboli. Mean attenuation values of ascending aortas and main pulmonary arteries in group 1 (n = 244) were compared with those in groups 2 and 3 (n = 45) by means of the two-tailed Student t test for unpaired data (P <.05). RESULTS: Attenuation values for ascending aortas in group 1 were significantly lower than those in groups 2 and 3 (P <.001). Attenuation values in main pulmonary arteries were significantly higher in group 1 than in groups 2 and 3 (P <.001). Echocardiographic images showed an intracardiac right-to-left shunt in all 39 cases with abnormal contrast dynamics in the CT study (16% of the whole study population). Three patients had an atrial-septal defect, and 36 had a PFO. Images with a shunt had good (9%), intermediate (37%), fair (33%), and poor (23%) contrast of the pulmonary arteries. Sufficient vessel contrast for the diagnosis of PE could not be achieved in 27 of 45 patients with a shunt, but severe central PE could be ruled out. PE could be diagnosed in 31% of the 244 images, 58% were negative, and 11% were indeterminate. CONCLUSION: A PFO may frequently lead to insufficient attenuation of the pulmonary arteries, which potentially limits the diagnosis of PE if the examination is performed during deep inspiration.

[Demineralising osteopathies: new aspects of diagnostic imaging]. / Demineralisierende Osteopathien: neue Aspekte der radiologischen Diagnostik.

The wide use of multimodal radiologic analysis of bone tissue has led to a new concept of the term osteopenia towards grouping the various osteopathies as demineralizing osteopathies. With bone densitometry measurements both high precision and accuracy can be achieved, whereas conventional radiographs provide insights into the architecture of the bone to better advantage. By using both modalities discrepancies of the radiological reports with the final diagnosis may be avoided. Despite ongoing success in techniques of semi-automated data analysis and reporting the radiological and the clinical assessment of bone diseases are still an indispensable part of establishing the diagnosis.

Ankylosing spondylitis, psoriatic arthritis, and reactive arthritis show increased bone resorption, but differ with regard to bone formation.

OBJECTIVE: To test if markers of bone metabolism are altered in patients with seronegative spondyloarthropathies (SSpA). METHODS: We studied biochemical markers of bone resorption and bone formation, osteoprotegerin (OPG), and bone mineral density (BMD) in patients with psoriatic arthritis (PsA), ankylosing spondylitis (AS), and reactive arthritis (ReA) and healthy volunteers. RESULTS: The bone resorption markers urinary deoxypyridinoline and crosslinked telopeptide of collagen-I were significantly increased in patients with AS, PsA, and ReA; in PsA they correlated with the acute phase response (C-reactive protein and erythrocyte sedimentation rate). The bone formation markers were divergent: bone-specific alkaline phosphatase was increased in PsA, but not in AS or ReA. Osteocalcin levels were only elevated in AS. Serum levels of OPG were significantly increased in both AS and PsA. Dual energy x-ray absorptiometry (DEXA) measurements of lumbar spine and femoral neck revealed osteopenia in patients with AS, whereas the DEXA distribution was within normal range in PsA. CONCLUSION: Our data indicate high and, particularly in AS, unbalanced bone turnover in SSpA, consistent with the decrease in BMD found in patients with AS.

Elimination of errors caused by first-order aliasing in velocity encoded cine-MR measurements of postoperative jets after aortic coarctation: in vitro and in vivo validation.

The aim of this study was to evaluate a velocity-encoded cine-MR (VEC-MR) sequence in measuring flow velocities up to two times the velocity encoding value (VENC) in a flow phantom and to validate the method for assessing poststenotic jet velocities in postoperative patients after aortic coarctation. In vitro, a flow phantom was used (0.5T; TR/TE: 51/8 ms, flip angle=30 degrees, FOV=280 mm, 128x256 matrix VENC 40 or 80 cm/s). On binary images, maximum flow velocities (V(max)) were calculated with a region of interest (ROI, 8 pixels). With aliasing, V(max) was calculated by VENC+(V(aliasing)). In vivo, 16 postoperative patients after aortic coarctation underwent double-oblique VEC-MR imaging through the aortic arch (ECG triggering, 16 phases/RR, TR=600-800 ms, flow-encoding cranio-caudal, VENC=2 m/s). Peak systolic velocities were measured and transthoracic Doppler echocardiography (TTDE) was performed. In vitro, there were excellent correlations for MR velocity measurements with and without aliasing ( r=0.99) and for true and MR-derived flow velocities ( r=0.99). In vivo, there was good correlation between VEC-MR and TTDE-assessed V(max) values in the aorta at the former coarctation site ( r=0.90, n=16). Aliasing occurred in 13 patients. VEC-MR is a useful modality for assessing jet velocities in the follow-up of patients after aortic coarctation. Despite of aliasing, accurate velocity measurements up to two times VENC are possible using binary images.