[Thrombotic thrombocytopenic purpura and ankylosing spondylarthritis. Apropos of a case]. / Purpura thrombotique thrombocytopénique et spondylarthrite ankylosante. A propos d'un cas.

The authors report a case of thrombotic thrombocytopenic purpura (TTP) which revealed a hitherto unrecognized ankylosing spondylitis. After a 4-year follow-up, the spondylitis is still progressing in its axial and/or peripheral form, and TTP has not relapsed. TTP is usually primary, but numerous forms consecutive to various diseases, and notably autoimmune diseases, have been reported. The TTP-ankylosing spondylitis association is extremely rare: analysis of the literature yielded only one case. The authors discuss the hypothesis of a common triggering factor.

[Bone histomorphometric study in involuted fractured osteoporosis treated with 1-ethane-1-hydroxybiphosphonate (etidronate) during one year]. / Etude histomorphométrique osseuse dans l'ostéoporose fracturaire d'involution traitée par l'éthane-1, hydroxy-1, 1 bisphosphonate (étidronate) pendant un an.

The efficacy of the biphosphonate etidronate has recently been demonstrated versus the vertebral fracture rate in fractured involuted osteoporosis in the literature. However, it would appear that the increase in bone mass (measured from the calcium density) may alone account for these results. The authors undertook a histomorphometrie study in 20 patients with a group mean age of 55 years presenting recent vertebral fracture in the context of osteoporosis, in order to assess the cell changes which may affect bone quality. This factor remains the only one which can account for the reduced number of fractures. The patients received treatment with phosphorus (1,500 mg/d) for 3 days followed by etidronate (400 mg/d) for 14 days every 90 days. A permanent daily intake of 50 mg of calcium and 400 IU of vitamin D was also administered. Each patient underwent bone biopsy of the iliac wing before and after one year of treatment (4 cycles). No change in the bone mass or architectural parameters was observed. However, general slowing of the bone remodeling was found, affecting the natality and activity of the osteoforming and osteoresorbing cells. However, this remodeling which is traditionally uncoupled in osteoporosis was once more coupled. This results in a slowing of bone loss, ageing of the bone present and no change in the architecture. Thus, the diphosphonates appear to have a beneficial effect on the quality of bone rather than on its quantity. This represents a novel approach to the treatment of osteoporosis.

Cortical osteoclasts are less sensitive to etidronate than trabecular osteoclasts.

Acute osteoporosis after spinal cord injury is related to an early increase in osteoclastic resorption. Healthy subjects subjected to bed rest similarly increase their osteoclast number in trabecular bone. Bisphosphonates possess a highly antiosteoclastic activity. The effects of a 120 day bed rest period, with or without etidronate therapy on cortical bone were measured in 15 subjects. Cortical thickness and cortical porosity were measured on transiliac bone biopsies taken before and after the bed rest period. Osteoclasts were detected histochemically and were counted with a semiautomatic image analyzer. Cortical thickness, cortical porosity, and cortical osteoclast number were not significantly modified in subjects submitted to bed rest alone. In the etidronate-treated patients, cortical bone mass parameters were also found to be unaffected, but the most striking feature was that the osteoclast number was unchanged. Trabecular osteoclasts, on the contrary, were increased in the untreated subjects (+95.2%) but decreased in the treated subjects (-78%). Bone cells may have heterogeneous responses according to their trabecular or cortical location. Cortical osteoclasts seem to be unaffected by etidronate therapy.

Alcoholic cirrhosis and osteoporosis in men: a light and scanning electron microscopy study.

Subjects with chronic alcoholism are associated with a higher prevalence of bone fractures, compared with age-matched controls. However, the pathogenesis of alcoholic osteopathy remains poorly understood. In this study, the bone cells activities and the bone matrix were studied using different techniques such as bone morphometry, scanning electron microscopy and computer reconstruction. Male patients (N = 20), aged 59.1 +/- 10.1 years, presenting a chronic decompensated alcoholic cirrhosis, were admitted into this study. A histomorphometric analysis of a transiliac bone biopsy was done after a double tetracycline labeling of the bone. A scanning electron microscopy (SEM) study was performed on eight out of the 20 patients on an additional biopsy. The bone mass was significantly decreased in cirrhotic patients. A marked defect in the osteoblastic function was observed with reduced osteoid parameters, lower mean wall thickness, and slower bone formation rate leading to a thinning of bone trabeculae. Conversely, trabecular resorption surfaces were markedly increased. SEM examination of bone biopsies was also consistent with delayed and impaired osteoblastic activity leading to extended and scalloped resorption surfaces covered by unusually thin layers of calcified collagen fibers. The reduced osteoblastic activity associated with normal osteoclastic function appears to play a major role in the pathogenesis of alcoholic osteoporosis leading to decreased bone mass with thinner trabeculae.

Relationships between bone and skin atrophies during aging.

Bone mineral density (BMD) was measured in 133 female subjects (age: 61.7 +/- 16.3 years) by dual energy X-ray absorptiometry (DEXA). Vertebral bone mineral density (BMD; L1-L4) and BMD of the whole upper femoral extremity were taken into account. In addition, skinfold thickness was measured with a callipers on the dorsum of the nondominant hand. A significant negative correlation was found between skinfold thickness and age (r = -0.623, p less than 0.0001). Both vertebral and femoral BMD decreased with age and the slopes were similar to those observed by other authors. Skinfold thickness was significantly correlated with vertebral (r = 0.364, p less than 0.0001) and femoral BMD (r = 0.486, p less than 0.0001). Skin and bone are connective tissues whose extracellular matrix mainly contains type I collagen. It is postulated that age-related skin atrophy and bone atrophy have a common genetic mechanism. Skinfold thickness measurement may help in defining the women at risk for osteoporotic bone fractures who should be referred for a DEXA examination.

Effects of a bisphosphonate (1-hydroxy ethylidene-1,1 bisphosphonic acid) on osteoclast number during prolonged bed rest in healthy humans.

Acute osteoporosis is known to occur after immobilization in spinal cord injured patients and is related to an early increase in osteoclastic bone resorption. Whether osteoporosis develops in healthy immobilized human patients is still a matter of controversy. Furthermore, acute osteoporosis was thought to be a good model to study the effects of weightlessness on the human skeleton and to adapt preventive procedures. A bed rest experiment was developed in the USSR on 15 healthy human volunteers to determine the precise effects on bone structure and cell activities. A preventive protocol, including an anti-osteoclastic drug (1-hydroxyethylidene-1,1 bisphosphonic acid; K salt) was investigated. Two transiliac bone biopsies were performed on the 15 individuals before and at the end of the 120-day bed rest period. Undecalcified bone biopsies were studied with automatic and semi-automatic image analyzers specially devoted to bone histomorphometry. Trabecular bone volume, osteoid amount, and eroded surfaces were measured. Osteoclast number was measured after histochemical identification of tartrate-resistant acid phosphatase. After the bed rest period, an insignificant bone loss was observed in healthy humans while osteoclast number was highly increased. In bisphosphonate-treated subjects, osteoclast number was markedly reduced and so was osteoid amount. Bisphosphonates were shown to present a highly cytotoxic activity on osteoclasts, a finding that has never been demonstrated in normal subjects.

Evaluation of the osteoclastic population in iliac crest biopsies from 36 normal subjects: a histoenzymologic and histomorphometric study.

After histochemical staining of tartrate-resistant acid phosphatase (TRAP) activity, the total and active trabecular resorption surfaces and the number of osteoclasts were determined by histomorphometry on iliac crest biopsies from 36 healthy volunteers. The subjects were separated into three groups according to age and sex. Total trabecular resorption surface showed no significant variation in any group, but the fraction of active resorption surface was significantly higher in the older population. The number of TRAP cells per mm2 of section area, related to trabecular bone volume or surface, showed a significant increase in elderly subjects. The mean osteoclast interface was similar in all the groups. We found a significant decrease in resorption depth between young and old populations. These results are consistent with a reduced activity of bone-resorbing cells in advancing age. These normal values, established after histochemical identification of osteoclasts, may be applied for evaluating abnormal bone-resorbing cell activity in metabolic bone diseases.

Bone changes in alcoholic cirrhosis of the liver. A histomorphometric study.

The effects of alcoholic liver cirrhosis on the calcium, calciotropic hormones (parathyroid hormone and 25 hydroxy vitamin D) and testosterone were examined in twenty men. A transiliac bone biopsy was performed in each patient. A double tetracycline labeling was done in 17 patients. Radiological signs of osteoporosis (crushed vertebrae and rib fractures) were rarely observed but a low trabecular bone volume (BV/TV) was consistently encountered (BV/TV = 14.2 +/- 4.6; normal 18.8 +/- 4.8; p less than .001). Osteomalacic signs were never observed in spite of very low calcium and 25 hydroxy vitamin D levels in the blood. Increased osteoclastic eroded surfaces (ES/BS = 8.1 +/- 5.2; normal 3.7 +/- 1.1; p less than .001) were not related with an hyperparathyroidism but a significant correlation was found with testosterone levels (r = .45; p less than .05). Histodynamic measurements indicate a drastically decreased osteoblastic activity with a very low bone formation rate (BFR/BS = .009 +/- .001; normal .0175 +/- .0125; p less than .001). This could explain the net increase of eroded surfaces and that osteomalacia cannot be observed even in the presence of profound calcium and vitamin D changes in alcoholics.

Effects of a one-year administration of phosphate and intermittent calcitonin on bone-forming and bone-resorbing cells in involutional osteoporosis: a histomorphometric study.

The bone histomorphometric effects of intermittent phosphate and calcitonin therapy during 1 year were analyzed in 15 involutional osteoporotic patients. Phosphate was administered continuously (1.5 g/day) and calcitonin was injected during 5 days every third week (50 IU/day). The bone cell response was analyzed in two separate groups, according to the amount of trabecular bone present in the iliac bone biopsy: patients with trabecular bone volume (TBV) beyond the histomorphometric spontaneous fracture threshold (0.16 mm3/mm3) (group 1; 11 patients) and patients with TBV above this threshold (group 2; 4 patients). In group 1, the treatment significantly increased TBV from 0.113 +/- 0.025 to 0.156 +/- 0.046 mm3/mm3 by thickening the existing trabeculae rather than by creating new trabeculae; stimulation of bone formation rate (+ 50%) and significant reduction in active trabecular resorption surfaces (from 0.021 +/- 0.013 to 0.010 +/- 0.006 mm2/mm2; P less than .05) may have led to positive bone balance. In group 2, TBV was not changed because of the treatment's relative inefficiency for reducing the bone-resorbing cell activity, leading to likely persistent negative bone balance. Cortical thickness did not change in either group. This study confirms the positive effectiveness of continuous treatment with phosphate and intermittent calcitonin during 1 year on bone balance in involutional osteoporosis with low amount of bone. The lack of response in patients with normal amount of bone must be verified before raising the hypothesis of different bone cell activity and before anticipating the therapeutic response according to local bone mass besides bone remodeling status in osteoporosis.

Improved algorithms for automatic bone histomorphometry on a numerized image analysis system.

Quantitative histological methods have proved to be the most effective methods in bone disease research. Faster and more accurate techniques are currently needed. We have developed a simple digitized image analysis system which allows accurate measurements of trabecular bone mass. The algorithm is based on the 'four-connected sets' mathematical theory. Given a numerized image displayed by a CCD camera, the algorithm recognizes all possible four-connected sets and provides area measurements. The first procedure automatically eliminates small, irrelevant profiles (wrinkles, cell nuclei, etc.) while larger profiles are erased interactively. The second procedure similarly erases the artefactual defects within the trabeculae (artefactual cracks or empty osteocytic lacunae). The method was shown to be very accurate and time-saving.

[Relations between trabecular bone mass and the configuration in the space of the trabeculae of bone. Histomorphometric study of a population of 145 osteoporotic women]. / Relations entre la masse osseuse trabéculaire et la disposition dans l'espace des trabécules osseuses. Etude histomorphométrique d'une population de 145 femmes ostéoporotiques.

145 women with involution osteoporosis and at least one vertebral compression noted on X-Rays, underwent a biopsy of the iliac wing and measurement of the mean cortical thickness, trabecular bony volume and parameters concerning the spatial configuration of bony trabecules (MTPT = Mean Trabecular Plate Thickness, MTPD = Mean Trabercular Plate Density, MTPS = Mean Trabecular Plate Separation), reflecting respectively the thickness, the density and the separation of the trabecules. The results were compared with those of a series of 22 control women of the same age. The post-menopausal osteoporotic patients present a decreased VTO, MTPD and MTPS with normal MTPT. Patients with senile osteoporosis show no difference as compared to the control patients of the same age. Half of the patients had a VTO higher than the spontaneous vertebral fracture threshold. Involution osteoporosis where the VTO exceeds the threshold present a significant decrease of the number of bony trabecules without decreased thickness. There is a negative correlation between age and the number of trabecules; a linear correlation between VTO and thickness, between VTO and trabecular density confirming the close relationship between mass and spatial configuration of the bone. There is a geometric configuration between density and separation of the trabecules, indicating a great sensitivity of the microstructural framework of disorganized trabecular bone. These data show that a decreased bony mass is not the only physiopathological mechanism observed during involution osteoporosis. Alterations of the spatial configuration of the trabecules or the mechanical resistance of the bony matrix are additional factors, the role of which might have been underestimated.

Spatial distribution of trabeculae in iliac bone from 145 osteoporotic females.

145 women showing clinical and radiological signs of involutional osteoporosis of the spine were biopsed at the ilium for histomorphometric analysis of bone mass including trabecular bone volume and parameters reflecting the spatial distribution of bony elements (mean trabecular plate thickness, density and separation). Results were compared with an age-matched population of 22 healthy females. Postmenopausal osteoporotics (i.e. younger than 75 years) were characterized by a significant reduction in trabecular bone volume, plate density and thickness, while senile osteoporotics (i.e. older than 75 years) did not exhibit any difference with controls. 51% of the osteoporotic patients had a trabecular bone volume higher than the spontaneous vertebral crush threshold defined by Meunier. Osteoporotic patients with trabecular bone volume under the vertebral crush threshold had a significant decrease in all trabecular parameters. On the opposite, patients with trabecular bone volume above the vertebral crush threshold had only a significant decrease in the number of trabeculae. A negative correlation was found between age and plate density in both osteoporotic patients and controls. A linear correlation was found between trabecular bone volume and plate density, but thickness and density of trabecular plates were not correlated. This study confirms that involutional osteoporosis is not only a decreased bone mass disorder. A modified spatial distribution of trabeculae or a mechanically less resistant bone matrix could be additional factors.

[Contribution of bone biopsy with histomorphometry in the evaluation of monoclonal gammopathy]. / Apport de la biopsie osseuse avec histomorphométrie dans l'évaluation d'une gammapathie monoclonale.

Histomorphometric analysis of bone specimen from the iliac crest was performed to determine total trabecular resorption surface (TTRS) in 46 patients presenting with a monoclonal gammopathy, which was benign in 17 cases and malignant in 29 others. In benign gammopathies, 14 patients had normal TTRS; no adverse progression, representing a malignant B-cell lymphoproliferative disorder occurred after 40 months of follow-up. The three other patients presented increased areas of resorption in contact with lymphoplasmocyte nodules or pure plasmocytes and had an unfavorable course: multiple myeloma, Waldenström's disease, and chronic lymphocytic leukemia. In myeloma, an increase in TTRS was observed when the bone marrow is invaded confirming the dominant local activity of an "osteoclast activating factor". TTRS is all the more extensive according to bone marrow invasion or in IgA or light chain myeloma, all of which are especially destructive of bone. It thus appears that determination of TTRS by bone histomorphometry is of diagnostic importance to recognize the benign or malignant nature of the disorder and has prognostic value in case of multiple myeloma. Bone histomorphometry thus appears as a useful tool in the thorough assessment of monoclonal gammopathies.

Effects of a 120 day period of bed-rest on bone mass and bone cell activities in man: attempts at countermeasure.

The effects of immobilization on bone mass and bone remodeling in patients with spinal cord injuries are known to simulate weightlessness-induced bone changes in astronauts. Nevertheless, immobilization has never been investigated using histomorphometric studies in healthy volunteers. Twenty healthy male volunteers participated in a '120 day bed-rest' experiment in the USSR. Bone biopsy cores of iliac crest were taken before and at the end of the period of bed-rest. The subjects were divided into five groups. Five subjects underwent a normal ambulatory life (control subjects); three subjects were placed on continuous bed-rest for 120 days (complete immobilization); four subjects were immobilized and underwent a controlled training program; four subjects were immobilized and received treatment with potassium diphosphonate (ethane-1,hydroxy-1,diphosphonate 900 mg/day, per os); and four subjects were immobilized and received diphosphonate plus physical exercise. Parameters of bone mass and bone cellular activities (osteoblastic formation and osteoclastic resorption) were measured using automatic and semi-automatic image analysis systems. Bone mass remained constant in each group. Cellular activity measurements showed that in completely immobilized men, the mineralization rate was lower than in controls without change in osteoid parameters; in contrast, osteoclastic parameters were increased. In immobilized men given the training program, bone formation was normal and bone resorption was increased. In immobilized men treated with diphosphonate, osteoid parameters and resorption activity were decreased. In immobilized men with diphosphonate plus training, the osteoid parameters and the resorption activity were reduced but to a lesser degree than in immobilized men with diphosphonate alone. Failure of bone loss in normal immobilized subjects differed from results found in paraplegic patients. However, a decrease in mineralization rate and an increase in bone resorption activity were found in both studies. Exercise stimulated bone resorption and diphosphonate inhibited the osteoclastic activity. These data emphasize the difficulties in finding good models to stimulate spaceflight conditions on earth. Comparative studies must be done using bone biopsies to determine more precisely the effects of weightlessness on the human skeleton.

[The bone in non-corticoid-treated sarcoidosis. A histomorphometric study]. / L'os de la sarcoïdose non cortisonée. Etude histomorphométrique.

The sarcoidosis granuloma secretes 1-25 dihydroxyvitamin D (1-25(OH)2 D) at the origin of the hypercalcemia found in about 20 p. cent of sarcoidoses. Its mechanism was considered exclusively of a digestive nature, but the activity of osteoclastic stimulation of 1-25(OH)2 D must consider an associated bony origin. Nine patients with bouts of non-steroid sarcoidosis were studied by osseous histomorphometric analysis. In a patient with hypercalcemia and radiographic manifestations, a high degree of bone remodelling is demonstrated, with stimulation of osteoclastic and osteoblastic activity. In eight patients with normocalcemia, two subgroups are individualized: two patients present intramedullary sarcoidosis granulomas with increased contact resorption; six patients present a normal marrow: the total areas of resorption remain increased. It is concluded that the activity of osteoclastic resorption is increased in sarcoidosis, which may explain partially the hypercalcemia. The absence of titration of 1-25(OH)2 D in our study does not permit to precise the role of this enzyme in the genesis of hyperosteoclastosis, although this seems quite plausible.

Effects of weightlessness on bone mass and osteoclast number in pregnant rats after a five-day spaceflight (COSMOS 1514).

Five pregnant growing rats were orbited for 5 days aboard the Soviet COSMOS 1514 biologic satellite. The bone effects of weightlessness were studied and compared to those of five pregnant rats kept in vivarium and five pregnant conditioned rats. Bone histomorphometric studies were performed to investigate the early effects of weightlessness in loaded (tibia-femur) and unloaded (thoracic and lumbar vertebrae) bones. A short exposure to weightlessness does not induce any change in bone mass and inner structure in either type of bone. In unloaded bones, the number of osteoclasts per square millimeter of the trabecular surface significantly increased when measured after histochemical demonstration of tartrate-resistant acid phosphatase. It is likely that a stimulation of bone resorption activity occurs in the trabeculae of unloaded bones during the early phase of a spaceflight. In tibia, osteoid seam thickness and total osteoclastic resorption surfaces at the endosteal level were not modified.

[Effects of weightlessness on osseous tissue of the rat after a space flight of 5 days (Cosmos 1514)]. / Effets de l'apesanteur sur le tissu osseux de rat après un vol spatial de cinq jours (Cosmos 1514).

Five pregnant female growing rats have been orbited for five days aboard the Cosmos 1514 soviet biological satellite. They were compared to five female rats kept in vivarium and five female conditioned rats in synchronised way. Histomorphometric studies were performed in order to investigate: 1. The early effects of weightlessness on the bone mass in loading (tibiae and femur) and unloading bones (thoracic and lumbar vertebrae). 2. The changes of osteoblastic and osteoclastic activities. A short exposure does not induce changes in the bone mass and the inner structure of loading and unloading bones. These results fit in well with human data available in the literature: they show that weightlessness doesn't change bone mass in the early phase of a spaceflight. However extrapolation of animal results to men is discussed. In unloading bones (vertebrae) osteoblastic activity was not measurable. Osteoclasts detected by histoenzymologic method don't change as far as their number per mm3 of trabecular bone is concerned. However the number per mm2 of trabecular area increases. It seems likely that an increase of the osteoclastic population occurs in trabecular bone. In loading bones, formation activity (appreciated by the measurement of osteoid seam thickness) and total osteoclastic resorption surfaces were not modified. These results are different from those of longer flights.

Bone embedding in pure methyl methacrylate at low temperature preserves enzyme activities.

Pure Methyl Methacrylate (MMA), a widely used embedding medium for undecalcified bone studies, was polymerized at low temperature (4 degrees C). MMA was prepared by a new purification procedure yielding a absolutely anhydrous and catalysed resin. The redox system benzoyle peroxide/NN-Dimethylanilin was used as the catalyzer-initiator system providing free radicals for the MMA chemical polymerization. Since the reaction is inhibited at -20 degrees C, complete infiltration of blocks is achieved within 3 d. Polymerization took place at +4 degrees C. The method provides undecalcified bone sections suitable for histomorphometric analysis of osteoid tissue, tetracycline bone labeling and Tartrate Resistant Acid Phosphatase. Enzyme histochemistry was shown to be possible in pure MMA embedded bones, when this low temperature embedding was used.