Osteoarthritis

SAN DIEGO — Vitamin D deficiency is underdiagnosed in the nursing home population, according to results from a single-center pilot study.

“Vitamin D deficiency has a huge number of ramifications in terms of increasing fall risk and decreasing strength,” Dr. Christine Simonelli said in an interview during a poster session at the annual meeting of the International Society for Clinical Densitometry. “It's also associated with osteoporosis. Nursing home residents are very often vitamin D deficient because the main source of vitamin D is sunlight.”

She and her associates assessed the prevalence of low bone density and vitamin D deficiency in 49 Caucasian residents of a St. Paul-area nursing home. They reviewed the medical charts of all study participants, used a calcaneal ultrasound machine to measure their bone density, and obtained 25-hydroxyvitamin D levels by serum sample.

The mean age of the residents in the study was 85 years, and 38 were female, said Dr. Simonelli, director of osteoporosis services for HealthEast Care System, Woodbury, Minn. Sixteen residents (33%) were taking a multivitamin supplement that contained vitamin D, and 10 (20%) were taking an additional vitamin D supplement.

Serum vitamin D levels ranged from 6 to 74 ng/mL, with a mean of 22.4 ng/mL. In fact, 35 residents (71%) had levels below the recommended range of 30–32 ng/mL.

Residents taking a multivitamin supplement had a mean vitamin D level of 29 ng/mL.

The mean calcaneal T score was −2.5; 45 (92%) had a score below −1.0, while 26 (53%) had a score below −2.5.

Nine residents (18%) had a diagnosis of osteoporosis in their medical records, and 6 of those residents (12%) were on bisphosphonate therapy.

In addition, 11 residents (22%) had a fall in the previous 30 days, while 35 (71%) had a fall in the previous 180 days.

After the researchers adjusted for age and sex, they found that vitamin D levels did not have a significant association with T-score category or fall rate.

“This pilot project was limited to one nursing home and had a small sample size,” the researchers noted in the report. “Bone density study was limited to peripheral scan type and no confirmatory DXA was performed.”

They also acknowledged that “inclusion of wheelchair-bound residents may have affected fall rate, vitamin D levels, and calcaneal ultrasound values.”

SAN DIEGO — Vitamin D deficiency is underdiagnosed in the nursing home population, according to results from a single-center pilot study.

“Vitamin D deficiency has a huge number of ramifications in terms of increasing fall risk and decreasing strength,” Dr. Christine Simonelli said in an interview during a poster session at the annual meeting of the International Society for Clinical Densitometry. “It's also associated with osteoporosis. Nursing home residents are very often vitamin D deficient because the main source of vitamin D is sunlight.”

She and her associates assessed the prevalence of low bone density and vitamin D deficiency in 49 Caucasian residents of a St. Paul-area nursing home. They reviewed the medical charts of all study participants, used a calcaneal ultrasound machine to measure their bone density, and obtained 25-hydroxyvitamin D levels by serum sample.

The mean age of the residents in the study was 85 years, and 38 were female, said Dr. Simonelli, director of osteoporosis services for HealthEast Care System, Woodbury, Minn. Sixteen residents (33%) were taking a multivitamin supplement that contained vitamin D, and 10 (20%) were taking an additional vitamin D supplement.

Serum vitamin D levels ranged from 6 to 74 ng/mL, with a mean of 22.4 ng/mL. In fact, 35 residents (71%) had levels below the recommended range of 30–32 ng/mL.

Residents taking a multivitamin supplement had a mean vitamin D level of 29 ng/mL.

The mean calcaneal T score was −2.5; 45 (92%) had a score below −1.0, while 26 (53%) had a score below −2.5.

Nine residents (18%) had a diagnosis of osteoporosis in their medical records, and 6 of those residents (12%) were on bisphosphonate therapy.

In addition, 11 residents (22%) had a fall in the previous 30 days, while 35 (71%) had a fall in the previous 180 days.

After the researchers adjusted for age and sex, they found that vitamin D levels did not have a significant association with T-score category or fall rate.

“This pilot project was limited to one nursing home and had a small sample size,” the researchers noted in the report. “Bone density study was limited to peripheral scan type and no confirmatory DXA was performed.”

They also acknowledged that “inclusion of wheelchair-bound residents may have affected fall rate, vitamin D levels, and calcaneal ultrasound values.”

SAN DIEGO — Vitamin D deficiency is underdiagnosed in the nursing home population, according to results from a single-center pilot study.

“Vitamin D deficiency has a huge number of ramifications in terms of increasing fall risk and decreasing strength,” Dr. Christine Simonelli said in an interview during a poster session at the annual meeting of the International Society for Clinical Densitometry. “It's also associated with osteoporosis. Nursing home residents are very often vitamin D deficient because the main source of vitamin D is sunlight.”

She and her associates assessed the prevalence of low bone density and vitamin D deficiency in 49 Caucasian residents of a St. Paul-area nursing home. They reviewed the medical charts of all study participants, used a calcaneal ultrasound machine to measure their bone density, and obtained 25-hydroxyvitamin D levels by serum sample.

The mean age of the residents in the study was 85 years, and 38 were female, said Dr. Simonelli, director of osteoporosis services for HealthEast Care System, Woodbury, Minn. Sixteen residents (33%) were taking a multivitamin supplement that contained vitamin D, and 10 (20%) were taking an additional vitamin D supplement.

Serum vitamin D levels ranged from 6 to 74 ng/mL, with a mean of 22.4 ng/mL. In fact, 35 residents (71%) had levels below the recommended range of 30–32 ng/mL.

Residents taking a multivitamin supplement had a mean vitamin D level of 29 ng/mL.

The mean calcaneal T score was −2.5; 45 (92%) had a score below −1.0, while 26 (53%) had a score below −2.5.

Nine residents (18%) had a diagnosis of osteoporosis in their medical records, and 6 of those residents (12%) were on bisphosphonate therapy.

In addition, 11 residents (22%) had a fall in the previous 30 days, while 35 (71%) had a fall in the previous 180 days.

After the researchers adjusted for age and sex, they found that vitamin D levels did not have a significant association with T-score category or fall rate.

“This pilot project was limited to one nursing home and had a small sample size,” the researchers noted in the report. “Bone density study was limited to peripheral scan type and no confirmatory DXA was performed.”

They also acknowledged that “inclusion of wheelchair-bound residents may have affected fall rate, vitamin D levels, and calcaneal ultrasound values.”

SAN DIEGO — Scanning just the dominant forearm of patients with a history of nondominant wrist fracture can miss cases of osteoporosis.

More cases of osteoporosis were diagnosed when both forearms were scanned with dual-energy x-ray absorptiometry (DXA) than when the dominant side alone was scanned, Pam Johnson reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“We're missing 10%–15% of cases by doing [a scan of] just the dominant forearm, which is the rule” in these cases, Ms. Johnson, a certified radiologic technologist with the St. Paul, Minn.-based HealthEast Osteoporosis Care Clinic, said in an interview. “That [rule] should be reevaluated.”

In what she said is the first study of its kind, Ms. Johnson and her associates performed bilateral forearm DXA scans on 39 patients with a history of nondominant forearm fractures.

The mean one-third radius bone mineral density T score was −2.0 on the dominant side and −2.2 on the nondominant side. The nondominant radius DXA scan identified osteoporosis in 17 patients, 4 of whom were osteopenic on the dominant side.

The dominant radius DXA scan identified osteoporosis in 16 patients, 3 of whom were not osteoporotic on the nondominant side.

In addition, the researchers found that one patient had a normal T score on the dominant side but had osteopenia on the fractured, nondominant side.

“The number of patients diagnosed with osteoporosis increased from 16 to 20 if we scanned both the dominant and nondominant forearm, compared with scanning just the dominant side alone in the situation of a nondominant wrist fracture,” the researchers wrote in their poster. “Overall, 10% more patients were diagnosed with osteoporosis when both forearms were scanned.”

A key limitation of the study is its small sample size. Another, they wrote, is the fact that “forearm fracture history was not adjudicated but taken from personal history and therefore the location of the fracture may not always be correct.”

An estimated 250,000 wrist fractures occur each year in the United States.

SAN DIEGO — Scanning just the dominant forearm of patients with a history of nondominant wrist fracture can miss cases of osteoporosis.

More cases of osteoporosis were diagnosed when both forearms were scanned with dual-energy x-ray absorptiometry (DXA) than when the dominant side alone was scanned, Pam Johnson reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“We're missing 10%–15% of cases by doing [a scan of] just the dominant forearm, which is the rule” in these cases, Ms. Johnson, a certified radiologic technologist with the St. Paul, Minn.-based HealthEast Osteoporosis Care Clinic, said in an interview. “That [rule] should be reevaluated.”

In what she said is the first study of its kind, Ms. Johnson and her associates performed bilateral forearm DXA scans on 39 patients with a history of nondominant forearm fractures.

The mean one-third radius bone mineral density T score was −2.0 on the dominant side and −2.2 on the nondominant side. The nondominant radius DXA scan identified osteoporosis in 17 patients, 4 of whom were osteopenic on the dominant side.

The dominant radius DXA scan identified osteoporosis in 16 patients, 3 of whom were not osteoporotic on the nondominant side.

In addition, the researchers found that one patient had a normal T score on the dominant side but had osteopenia on the fractured, nondominant side.

“The number of patients diagnosed with osteoporosis increased from 16 to 20 if we scanned both the dominant and nondominant forearm, compared with scanning just the dominant side alone in the situation of a nondominant wrist fracture,” the researchers wrote in their poster. “Overall, 10% more patients were diagnosed with osteoporosis when both forearms were scanned.”

A key limitation of the study is its small sample size. Another, they wrote, is the fact that “forearm fracture history was not adjudicated but taken from personal history and therefore the location of the fracture may not always be correct.”

An estimated 250,000 wrist fractures occur each year in the United States.

SAN DIEGO — Scanning just the dominant forearm of patients with a history of nondominant wrist fracture can miss cases of osteoporosis.

More cases of osteoporosis were diagnosed when both forearms were scanned with dual-energy x-ray absorptiometry (DXA) than when the dominant side alone was scanned, Pam Johnson reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“We're missing 10%–15% of cases by doing [a scan of] just the dominant forearm, which is the rule” in these cases, Ms. Johnson, a certified radiologic technologist with the St. Paul, Minn.-based HealthEast Osteoporosis Care Clinic, said in an interview. “That [rule] should be reevaluated.”

In what she said is the first study of its kind, Ms. Johnson and her associates performed bilateral forearm DXA scans on 39 patients with a history of nondominant forearm fractures.

The mean one-third radius bone mineral density T score was −2.0 on the dominant side and −2.2 on the nondominant side. The nondominant radius DXA scan identified osteoporosis in 17 patients, 4 of whom were osteopenic on the dominant side.

The dominant radius DXA scan identified osteoporosis in 16 patients, 3 of whom were not osteoporotic on the nondominant side.

In addition, the researchers found that one patient had a normal T score on the dominant side but had osteopenia on the fractured, nondominant side.

“The number of patients diagnosed with osteoporosis increased from 16 to 20 if we scanned both the dominant and nondominant forearm, compared with scanning just the dominant side alone in the situation of a nondominant wrist fracture,” the researchers wrote in their poster. “Overall, 10% more patients were diagnosed with osteoporosis when both forearms were scanned.”

A key limitation of the study is its small sample size. Another, they wrote, is the fact that “forearm fracture history was not adjudicated but taken from personal history and therefore the location of the fracture may not always be correct.”

An estimated 250,000 wrist fractures occur each year in the United States.

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States.

They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

Concomitant medications were defined as a minimum of a 2-week supply of medications that are prescribed in the same month as are a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286. Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more.

The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, β-blockers, ACE inhibitors, and systemic antiarthritis medications.

Dr. Bonnick and her associates observed that by the end of the study, women on daily bisphosphonate therapy were on a higher mean number of concomitant medications, compared with those on weekly bisphosphonate therapy (4.16 vs. 3.77, respectively). In addition, women aged 75 years and older were on a higher mean number of concomitant medications, compared with those aged 50–64 years (3.97 vs. 3.09, respectively).

GlaxoSmithKline supported the study.

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States.

They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

Concomitant medications were defined as a minimum of a 2-week supply of medications that are prescribed in the same month as are a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286. Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more.

The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, β-blockers, ACE inhibitors, and systemic antiarthritis medications.

Dr. Bonnick and her associates observed that by the end of the study, women on daily bisphosphonate therapy were on a higher mean number of concomitant medications, compared with those on weekly bisphosphonate therapy (4.16 vs. 3.77, respectively). In addition, women aged 75 years and older were on a higher mean number of concomitant medications, compared with those aged 50–64 years (3.97 vs. 3.09, respectively).

GlaxoSmithKline supported the study.

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States.

They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

Concomitant medications were defined as a minimum of a 2-week supply of medications that are prescribed in the same month as are a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286. Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more.

The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, β-blockers, ACE inhibitors, and systemic antiarthritis medications.

Dr. Bonnick and her associates observed that by the end of the study, women on daily bisphosphonate therapy were on a higher mean number of concomitant medications, compared with those on weekly bisphosphonate therapy (4.16 vs. 3.77, respectively). In addition, women aged 75 years and older were on a higher mean number of concomitant medications, compared with those aged 50–64 years (3.97 vs. 3.09, respectively).

GlaxoSmithKline supported the study.

FORT LAUDERDALE, FLA. — The use of

In Paget's disease of bone, biochemical markers are used to monitor treatment response. But, in patients with limited bone involvement, these global indices often remain in the normal range, said Dr. Devogelaer, professor of rheumatology at Catholic University of Louvain and Saint-Luc University Hospital, Brussels.

Positron emission tomography (PET) using

Twelve patients with monostotic Paget's disease underwent 1-hour dynamic

Changes in bone metabolism as measured by the PET scans were assessed in two ways: via dynamic plasma clearance of

The two values correlated with each other at all time points. Both showed huge activity prior to treatment and significant drops thereafter, by about 30% at 1 month, 40% at 6 months, and nearly 50% at 1 year.

In contrast, the biochemical markers correlated with the PET scan results at baseline but not after treatment: Total alkaline phosphatase dropped by about 25% at 1 year, but remained within the normal range throughout the study. Fasting levels of urinary N-terminal cross-linking telopeptide of type I collagen (NTX) decreased significantly up to 6 months, but not thereafter. Bone-specific alkaline phosphatase dropped by about 30%–35% at 1 month, but remained significant only up to 6 months. Such changes in biochemical markers are not adequate for follow-up, he noted.

In response to a comment that PET scans are expensive, Dr. Devogelaer said, “We hope that the cost will decrease. But, we see that with the biological parameters, there is no correlation after treatment. To appreciate the activity of monostotic Paget's disease of bone, we need something else.”

FORT LAUDERDALE, FLA. — The use of

In Paget's disease of bone, biochemical markers are used to monitor treatment response. But, in patients with limited bone involvement, these global indices often remain in the normal range, said Dr. Devogelaer, professor of rheumatology at Catholic University of Louvain and Saint-Luc University Hospital, Brussels.

Positron emission tomography (PET) using

Twelve patients with monostotic Paget's disease underwent 1-hour dynamic

Changes in bone metabolism as measured by the PET scans were assessed in two ways: via dynamic plasma clearance of

The two values correlated with each other at all time points. Both showed huge activity prior to treatment and significant drops thereafter, by about 30% at 1 month, 40% at 6 months, and nearly 50% at 1 year.

In contrast, the biochemical markers correlated with the PET scan results at baseline but not after treatment: Total alkaline phosphatase dropped by about 25% at 1 year, but remained within the normal range throughout the study. Fasting levels of urinary N-terminal cross-linking telopeptide of type I collagen (NTX) decreased significantly up to 6 months, but not thereafter. Bone-specific alkaline phosphatase dropped by about 30%–35% at 1 month, but remained significant only up to 6 months. Such changes in biochemical markers are not adequate for follow-up, he noted.

In response to a comment that PET scans are expensive, Dr. Devogelaer said, “We hope that the cost will decrease. But, we see that with the biological parameters, there is no correlation after treatment. To appreciate the activity of monostotic Paget's disease of bone, we need something else.”

FORT LAUDERDALE, FLA. — The use of

In Paget's disease of bone, biochemical markers are used to monitor treatment response. But, in patients with limited bone involvement, these global indices often remain in the normal range, said Dr. Devogelaer, professor of rheumatology at Catholic University of Louvain and Saint-Luc University Hospital, Brussels.

Positron emission tomography (PET) using

Twelve patients with monostotic Paget's disease underwent 1-hour dynamic

Changes in bone metabolism as measured by the PET scans were assessed in two ways: via dynamic plasma clearance of

The two values correlated with each other at all time points. Both showed huge activity prior to treatment and significant drops thereafter, by about 30% at 1 month, 40% at 6 months, and nearly 50% at 1 year.

In contrast, the biochemical markers correlated with the PET scan results at baseline but not after treatment: Total alkaline phosphatase dropped by about 25% at 1 year, but remained within the normal range throughout the study. Fasting levels of urinary N-terminal cross-linking telopeptide of type I collagen (NTX) decreased significantly up to 6 months, but not thereafter. Bone-specific alkaline phosphatase dropped by about 30%–35% at 1 month, but remained significant only up to 6 months. Such changes in biochemical markers are not adequate for follow-up, he noted.

In response to a comment that PET scans are expensive, Dr. Devogelaer said, “We hope that the cost will decrease. But, we see that with the biological parameters, there is no correlation after treatment. To appreciate the activity of monostotic Paget's disease of bone, we need something else.”

FORT LAUDERDALE, FLA. — Screening for vitamin D deficiency should be part of the initial evaluation of patients with Paget's disease, Dr. Jennifer J. Kelly and Dr. Arnold M. Moses said in a poster presentation at a meeting sponsored by the Paget Foundation for Paget's Disease of Bone and Related Disorders.

Blood collected from 37 patients (mean age 72) at their initial visit to a metabolic bone clinic revealed that just three (8%) had levels of 25(OH)D considered to be optimal (greater than 32 ng/mL), while 21 (58%) were vitamin D deficient (below 20 ng/mL), said the study investigators, of the State University of New York Upstate Medical University, Syracuse.

The median 25(OH)D level among the 24 men in the group was 20 ng/mL, compared with just 13 ng/mL among the 13 women.

Women were more likely than men (5 vs. 2) to be grossly vitamin D deficient (0–9 ng/mL), while men were in the majority in the intermediate range between 10 and 32 ng/mL (20 men vs. 7 women).

Levels greater than 32 ng/mL were seen in only two men and one woman.

Season also influenced 25(OH) D levels, which were on average 9 ng/mL higher during the “light” months of the year (May-September) than during the “dark” period of November-March.

Of the 13 patients whose blood had been collected during the light months, 7 (54%) had 25(OH)D levels of 20 ng/mL or above, compared with just 3 (20%) of the 15 sampled during the dark months. Women had lower median vitamin D levels than men in both the light and dark months.

The initial idea for this investigation came from a patient seen in the metabolic bone clinic who had both hypovitaminosis D and documented active Paget's disease of the tibia with intense pain in the area.

The pain resolved completely when the patient's vitamin D deficiency was treated.

Aside from reducing musculoskeletal pain, other potential benefits of correcting hypovitaminosis D in patients with Paget's disease include ensuring that markers of bone turnover actually reflect Paget's disease activity, decreasing fracture risk, improving muscle strength and balance, and reducing the risks of both hypocalcemia and osteomalacic new bone formation resulting from bisphosphonate treatment, Dr. Kelly and Dr. Moses said.

FORT LAUDERDALE, FLA. — Screening for vitamin D deficiency should be part of the initial evaluation of patients with Paget's disease, Dr. Jennifer J. Kelly and Dr. Arnold M. Moses said in a poster presentation at a meeting sponsored by the Paget Foundation for Paget's Disease of Bone and Related Disorders.

Blood collected from 37 patients (mean age 72) at their initial visit to a metabolic bone clinic revealed that just three (8%) had levels of 25(OH)D considered to be optimal (greater than 32 ng/mL), while 21 (58%) were vitamin D deficient (below 20 ng/mL), said the study investigators, of the State University of New York Upstate Medical University, Syracuse.

The median 25(OH)D level among the 24 men in the group was 20 ng/mL, compared with just 13 ng/mL among the 13 women.

Women were more likely than men (5 vs. 2) to be grossly vitamin D deficient (0–9 ng/mL), while men were in the majority in the intermediate range between 10 and 32 ng/mL (20 men vs. 7 women).

Levels greater than 32 ng/mL were seen in only two men and one woman.

Season also influenced 25(OH) D levels, which were on average 9 ng/mL higher during the “light” months of the year (May-September) than during the “dark” period of November-March.

Of the 13 patients whose blood had been collected during the light months, 7 (54%) had 25(OH)D levels of 20 ng/mL or above, compared with just 3 (20%) of the 15 sampled during the dark months. Women had lower median vitamin D levels than men in both the light and dark months.

The initial idea for this investigation came from a patient seen in the metabolic bone clinic who had both hypovitaminosis D and documented active Paget's disease of the tibia with intense pain in the area.

The pain resolved completely when the patient's vitamin D deficiency was treated.

Aside from reducing musculoskeletal pain, other potential benefits of correcting hypovitaminosis D in patients with Paget's disease include ensuring that markers of bone turnover actually reflect Paget's disease activity, decreasing fracture risk, improving muscle strength and balance, and reducing the risks of both hypocalcemia and osteomalacic new bone formation resulting from bisphosphonate treatment, Dr. Kelly and Dr. Moses said.

FORT LAUDERDALE, FLA. — Screening for vitamin D deficiency should be part of the initial evaluation of patients with Paget's disease, Dr. Jennifer J. Kelly and Dr. Arnold M. Moses said in a poster presentation at a meeting sponsored by the Paget Foundation for Paget's Disease of Bone and Related Disorders.

Blood collected from 37 patients (mean age 72) at their initial visit to a metabolic bone clinic revealed that just three (8%) had levels of 25(OH)D considered to be optimal (greater than 32 ng/mL), while 21 (58%) were vitamin D deficient (below 20 ng/mL), said the study investigators, of the State University of New York Upstate Medical University, Syracuse.

The median 25(OH)D level among the 24 men in the group was 20 ng/mL, compared with just 13 ng/mL among the 13 women.

Women were more likely than men (5 vs. 2) to be grossly vitamin D deficient (0–9 ng/mL), while men were in the majority in the intermediate range between 10 and 32 ng/mL (20 men vs. 7 women).

Levels greater than 32 ng/mL were seen in only two men and one woman.

Season also influenced 25(OH) D levels, which were on average 9 ng/mL higher during the “light” months of the year (May-September) than during the “dark” period of November-March.

Of the 13 patients whose blood had been collected during the light months, 7 (54%) had 25(OH)D levels of 20 ng/mL or above, compared with just 3 (20%) of the 15 sampled during the dark months. Women had lower median vitamin D levels than men in both the light and dark months.

The initial idea for this investigation came from a patient seen in the metabolic bone clinic who had both hypovitaminosis D and documented active Paget's disease of the tibia with intense pain in the area.

The pain resolved completely when the patient's vitamin D deficiency was treated.

Aside from reducing musculoskeletal pain, other potential benefits of correcting hypovitaminosis D in patients with Paget's disease include ensuring that markers of bone turnover actually reflect Paget's disease activity, decreasing fracture risk, improving muscle strength and balance, and reducing the risks of both hypocalcemia and osteomalacic new bone formation resulting from bisphosphonate treatment, Dr. Kelly and Dr. Moses said.

FORT LAUDERDALE, FLA. — Biochemical screening of patients with Paget's disease of bone should always include measurement of parathyroid hormone levels, Dr. Maria Luisa Brandi advised at a meeting sponsored by the Paget's Foundation for Paget's Disease of Bone and Related Disorders.

The coexistence of Paget's disease of bone and hyperparathyroidism, first described in 1948, is still not well understood. In studies, approximately 12%–18% of Paget's disease patients have elevated levels of parathyroid hormone (PTH), most of which represent secondary hyperparathyroidism. Yet measurement of PTH is still not routine, and “hyperparathyroidism in Paget's disease of bone is often overlooked,” said Dr. Brandi, professor of endocrinology and metabolism at the University of Florence, Italy.

Both Paget's disease and hyperparathyroidism are capable of causing bone pain, and bone biomarkers are elevated in both disorders. Increased marrow fibrosis and vascularity are common histologic features of both. But the two disorders differ in several histologic features. Hypercalcemia and hypercalciuria, only occasional findings in Paget's disease, are commonly seen in hyperparathyroidism. Malignant bone tumors are present in up to 1% of Paget's disease patients but are rare in hyperparathyroidism, she said at the conference, also sponsored by the National Institutes of Health and Columbia University, New York.

Increasing lines of evidence suggest that the cooccurrence of primary hyperparathyroidism with Paget's disease is due to the chance association of two diseases that are common in the elderly. Autopsy studies in Paget's disease patients failed to uncover consistent parathyroid gland abnormalities.

Furthermore, the prevalence and gender distribution of primary hyperparathyroidism in Paget's disease resembles that of the elderly population as a whole.

Most genetic studies have failed to find overlapping genes in the two disorders, but recent data suggest there might be some interactions among gene products, she noted.

Regardless of etiology, an excess of PTH is likely to have an exaggerated impact at skeletal sites affected by Paget's disease. Therefore, biochemical screening of patients with Paget's disease should include evaluation of serum calcium, phosphate, and PTH.

Parathyroidectomy is indicated in patients found to have both disorders. Conversely, patients who have primary hyperparathyroidism and high bone turnover after parathyroidectomy should undergo diagnostic screening for Paget's disease, Dr. Brandi recommended.

Secondary hyperparathyroidism can also result directly from the increased bone turnover in Paget's disease—a consequence of increased calcium demands during periods of pagetic bone formation—or from bisphosphonate treatment. Dietary supplementation with calcium and vitamin D can protect against this problem in patients undergoing bisphosphonate treatment, she said.

FORT LAUDERDALE, FLA. — Biochemical screening of patients with Paget's disease of bone should always include measurement of parathyroid hormone levels, Dr. Maria Luisa Brandi advised at a meeting sponsored by the Paget's Foundation for Paget's Disease of Bone and Related Disorders.

The coexistence of Paget's disease of bone and hyperparathyroidism, first described in 1948, is still not well understood. In studies, approximately 12%–18% of Paget's disease patients have elevated levels of parathyroid hormone (PTH), most of which represent secondary hyperparathyroidism. Yet measurement of PTH is still not routine, and “hyperparathyroidism in Paget's disease of bone is often overlooked,” said Dr. Brandi, professor of endocrinology and metabolism at the University of Florence, Italy.

Both Paget's disease and hyperparathyroidism are capable of causing bone pain, and bone biomarkers are elevated in both disorders. Increased marrow fibrosis and vascularity are common histologic features of both. But the two disorders differ in several histologic features. Hypercalcemia and hypercalciuria, only occasional findings in Paget's disease, are commonly seen in hyperparathyroidism. Malignant bone tumors are present in up to 1% of Paget's disease patients but are rare in hyperparathyroidism, she said at the conference, also sponsored by the National Institutes of Health and Columbia University, New York.

Increasing lines of evidence suggest that the cooccurrence of primary hyperparathyroidism with Paget's disease is due to the chance association of two diseases that are common in the elderly. Autopsy studies in Paget's disease patients failed to uncover consistent parathyroid gland abnormalities.

Furthermore, the prevalence and gender distribution of primary hyperparathyroidism in Paget's disease resembles that of the elderly population as a whole.

Most genetic studies have failed to find overlapping genes in the two disorders, but recent data suggest there might be some interactions among gene products, she noted.

Regardless of etiology, an excess of PTH is likely to have an exaggerated impact at skeletal sites affected by Paget's disease. Therefore, biochemical screening of patients with Paget's disease should include evaluation of serum calcium, phosphate, and PTH.

Parathyroidectomy is indicated in patients found to have both disorders. Conversely, patients who have primary hyperparathyroidism and high bone turnover after parathyroidectomy should undergo diagnostic screening for Paget's disease, Dr. Brandi recommended.

Secondary hyperparathyroidism can also result directly from the increased bone turnover in Paget's disease—a consequence of increased calcium demands during periods of pagetic bone formation—or from bisphosphonate treatment. Dietary supplementation with calcium and vitamin D can protect against this problem in patients undergoing bisphosphonate treatment, she said.

FORT LAUDERDALE, FLA. — Biochemical screening of patients with Paget's disease of bone should always include measurement of parathyroid hormone levels, Dr. Maria Luisa Brandi advised at a meeting sponsored by the Paget's Foundation for Paget's Disease of Bone and Related Disorders.

The coexistence of Paget's disease of bone and hyperparathyroidism, first described in 1948, is still not well understood. In studies, approximately 12%–18% of Paget's disease patients have elevated levels of parathyroid hormone (PTH), most of which represent secondary hyperparathyroidism. Yet measurement of PTH is still not routine, and “hyperparathyroidism in Paget's disease of bone is often overlooked,” said Dr. Brandi, professor of endocrinology and metabolism at the University of Florence, Italy.

Both Paget's disease and hyperparathyroidism are capable of causing bone pain, and bone biomarkers are elevated in both disorders. Increased marrow fibrosis and vascularity are common histologic features of both. But the two disorders differ in several histologic features. Hypercalcemia and hypercalciuria, only occasional findings in Paget's disease, are commonly seen in hyperparathyroidism. Malignant bone tumors are present in up to 1% of Paget's disease patients but are rare in hyperparathyroidism, she said at the conference, also sponsored by the National Institutes of Health and Columbia University, New York.

Increasing lines of evidence suggest that the cooccurrence of primary hyperparathyroidism with Paget's disease is due to the chance association of two diseases that are common in the elderly. Autopsy studies in Paget's disease patients failed to uncover consistent parathyroid gland abnormalities.

Furthermore, the prevalence and gender distribution of primary hyperparathyroidism in Paget's disease resembles that of the elderly population as a whole.

Most genetic studies have failed to find overlapping genes in the two disorders, but recent data suggest there might be some interactions among gene products, she noted.

Regardless of etiology, an excess of PTH is likely to have an exaggerated impact at skeletal sites affected by Paget's disease. Therefore, biochemical screening of patients with Paget's disease should include evaluation of serum calcium, phosphate, and PTH.

Parathyroidectomy is indicated in patients found to have both disorders. Conversely, patients who have primary hyperparathyroidism and high bone turnover after parathyroidectomy should undergo diagnostic screening for Paget's disease, Dr. Brandi recommended.

Secondary hyperparathyroidism can also result directly from the increased bone turnover in Paget's disease—a consequence of increased calcium demands during periods of pagetic bone formation—or from bisphosphonate treatment. Dietary supplementation with calcium and vitamin D can protect against this problem in patients undergoing bisphosphonate treatment, she said.

SAN DIEGO — Moderate to severe vertebral compression deformities are uncommon among postmenopausal women with osteopenia who lack a clinical history of fragility fracture, Dr. Angela M. Cheung reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

In what she described as the first study to describe the prevalence of vertebral deformities in healthy postmenopausal women with osteopenia, Dr. Cheung and her associates conducted a cross-sectional analysis of 439 women participating in the ongoing 2-year Evaluation of the Clinical Use of Vitamin K Supplementation in Postmenopausal Women with Osteopenia trial (ECKO).

Of the 48 deformities detected in the study, 45 (94%) were grade 1.

“The unknown is, how does that mild, grade 1 vertebral compression deformity translate to future fracture risk?” Dr. Cheung, director of the osteoporosis program for the University Health Network, Toronto, said in an interview. “We'll take a look at that. It's an ongoing study.”

Exclusion criteria included being on an osteoporosis medication, having a clinical fragility fracture, or having a T score of less than −2.0 at the lumbar spine, total hip, or femoral neck. Researchers used densitometry to measure bone mineral density and to perform a vertebral fracture assessment.

The mean patient age at baseline was 58 years, and mean body mass index was 26 kg/m

Baseline mean T scores were −1.2 for L1-L4, −0.6 for total hip, and −1.2 for femoral neck.

Baseline vertebral fracture assessment revealed that about 1 in 10 women had at least one vertebral compression deformity. Specifically, 8.7% had a single deformity, and 1.1% had two deformities.

Dr. Cheung said she was surprised to see the presence of vertebral compression deformities in women from all age groups. The age of study participants ranged from 40 to 82 years.

“While we do see a higher percentage of [older] people [with] vertebral compression deformities, we see it in [more] young people, too,” she said. “The gradient is from about 10% in the lowest age group to about 15% in the older age group.”

Two women (aged 56 and 60) had grade 2 deformities while one 74-year-old had a grade 3 deformity.

Limitations acknowledged by the researchers in their poster included the cross-sectional study design and a lack of lateral spine x-rays on the women for comparison.

However, they wrote that vertebral fracture assessment “has been validated by different groups, and the performance of the test is excellent for grades 2–4 deformities.”

While we see more vertebral deformities in older people, we see more in the young, too. DR. CHEUNG

A densitometer image shows a grade 1 L1 vertebral compression deformity. Courtesy Dr. Angela M. Cheung

SAN DIEGO — Moderate to severe vertebral compression deformities are uncommon among postmenopausal women with osteopenia who lack a clinical history of fragility fracture, Dr. Angela M. Cheung reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

In what she described as the first study to describe the prevalence of vertebral deformities in healthy postmenopausal women with osteopenia, Dr. Cheung and her associates conducted a cross-sectional analysis of 439 women participating in the ongoing 2-year Evaluation of the Clinical Use of Vitamin K Supplementation in Postmenopausal Women with Osteopenia trial (ECKO).

Of the 48 deformities detected in the study, 45 (94%) were grade 1.

“The unknown is, how does that mild, grade 1 vertebral compression deformity translate to future fracture risk?” Dr. Cheung, director of the osteoporosis program for the University Health Network, Toronto, said in an interview. “We'll take a look at that. It's an ongoing study.”

Exclusion criteria included being on an osteoporosis medication, having a clinical fragility fracture, or having a T score of less than −2.0 at the lumbar spine, total hip, or femoral neck. Researchers used densitometry to measure bone mineral density and to perform a vertebral fracture assessment.

The mean patient age at baseline was 58 years, and mean body mass index was 26 kg/m

Baseline mean T scores were −1.2 for L1-L4, −0.6 for total hip, and −1.2 for femoral neck.

Baseline vertebral fracture assessment revealed that about 1 in 10 women had at least one vertebral compression deformity. Specifically, 8.7% had a single deformity, and 1.1% had two deformities.

Dr. Cheung said she was surprised to see the presence of vertebral compression deformities in women from all age groups. The age of study participants ranged from 40 to 82 years.

“While we do see a higher percentage of [older] people [with] vertebral compression deformities, we see it in [more] young people, too,” she said. “The gradient is from about 10% in the lowest age group to about 15% in the older age group.”

Two women (aged 56 and 60) had grade 2 deformities while one 74-year-old had a grade 3 deformity.

Limitations acknowledged by the researchers in their poster included the cross-sectional study design and a lack of lateral spine x-rays on the women for comparison.

However, they wrote that vertebral fracture assessment “has been validated by different groups, and the performance of the test is excellent for grades 2–4 deformities.”

While we see more vertebral deformities in older people, we see more in the young, too. DR. CHEUNG

A densitometer image shows a grade 1 L1 vertebral compression deformity. Courtesy Dr. Angela M. Cheung

SAN DIEGO — Moderate to severe vertebral compression deformities are uncommon among postmenopausal women with osteopenia who lack a clinical history of fragility fracture, Dr. Angela M. Cheung reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

In what she described as the first study to describe the prevalence of vertebral deformities in healthy postmenopausal women with osteopenia, Dr. Cheung and her associates conducted a cross-sectional analysis of 439 women participating in the ongoing 2-year Evaluation of the Clinical Use of Vitamin K Supplementation in Postmenopausal Women with Osteopenia trial (ECKO).

Of the 48 deformities detected in the study, 45 (94%) were grade 1.

“The unknown is, how does that mild, grade 1 vertebral compression deformity translate to future fracture risk?” Dr. Cheung, director of the osteoporosis program for the University Health Network, Toronto, said in an interview. “We'll take a look at that. It's an ongoing study.”

Exclusion criteria included being on an osteoporosis medication, having a clinical fragility fracture, or having a T score of less than −2.0 at the lumbar spine, total hip, or femoral neck. Researchers used densitometry to measure bone mineral density and to perform a vertebral fracture assessment.

The mean patient age at baseline was 58 years, and mean body mass index was 26 kg/m

Baseline mean T scores were −1.2 for L1-L4, −0.6 for total hip, and −1.2 for femoral neck.

Baseline vertebral fracture assessment revealed that about 1 in 10 women had at least one vertebral compression deformity. Specifically, 8.7% had a single deformity, and 1.1% had two deformities.

Dr. Cheung said she was surprised to see the presence of vertebral compression deformities in women from all age groups. The age of study participants ranged from 40 to 82 years.

“While we do see a higher percentage of [older] people [with] vertebral compression deformities, we see it in [more] young people, too,” she said. “The gradient is from about 10% in the lowest age group to about 15% in the older age group.”

Two women (aged 56 and 60) had grade 2 deformities while one 74-year-old had a grade 3 deformity.

Limitations acknowledged by the researchers in their poster included the cross-sectional study design and a lack of lateral spine x-rays on the women for comparison.

However, they wrote that vertebral fracture assessment “has been validated by different groups, and the performance of the test is excellent for grades 2–4 deformities.”

While we see more vertebral deformities in older people, we see more in the young, too. DR. CHEUNG

A densitometer image shows a grade 1 L1 vertebral compression deformity. Courtesy Dr. Angela M. Cheung

SAN FRANCISCO — Measuring bone mineral density in older patients is as justifiable as measuring lipids, Dennis M. Black, Ph.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Lipid testing and treatment for high cholesterol is accepted as an integral part of primary care, but bone densitometry and treatment for low bone density isn't as readily accepted, said Dr. Black, professor of epidemiology and biostatistics at the university.

That's partly because measurements and treatments for osteoporosis came along well after tests and treatments for heart disease and its risk factors, he explained. The ready acceptance of lipid screening compared with bone density screening bothers some osteoporosis experts. “It might be called lipid envy,” he joked.

The value of bone density testing stacks up nicely against the value of lipid testing. Studies have shown that people with cholesterol measurements in the highest quartile have four times the risk for heart disease compared with people whose cholesterol measurements are in the lowest quartile, Dr. Black said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is in the lowest quartile compared with those in the highest quartile.

Heart disease risk increases from about 0.5% in the lowest low-density lipoprotein (LDL) quartile to about 4% in the highest lipid quartile. Hip fracture risk increases from about 0.5% in the highest quartile of hip bone density to about 10% in the quartile with the least hip bone density.

Cost-effectiveness compares well, too, he added. Screening lipid levels in a 52-year-old woman and treating her for an LDL level greater than 160 mg/dL costs about $400,000 per quality-adjusted life-year. Screening bone density in a 65-year-old woman and treating her with bisphosphonates for a T score of −2.5 (suggesting osteoporosis) costs about $30,000 per quality-adjusted life-year, “which is considered cost effective,” Dr. Black said.

The National Osteoporosis Foundation recommends bone mineral density testing for all women aged 65 years and older, and for postmenopausal women with a risk factor for osteoporosis.

The definition of risk factors for osteoporosis is a bit murky. Dr. Black includes postmenopausal women who have a history of fracture after menopause, whose mothers have a history of fracture (especially hip fracture), who take steroids, or who have very low body weight. Very low body weight commonly is considered being below 125 pounds, but that depends somewhat on height, he added.

The U.S. Preventive Services Task Force recommends bone mineral density measurements for all women above age 60. Medicare covers bone density tests for women over age 65.

Dr. Black recently analyzed 16 years of follow-up data on women in the Study of Osteoporotic Fractures and found that a single measurement of hip bone density is a good predictor of fracture risk. In these white women with a mean age of 71 years, 5% of those in the highest quartile of hip bone density developed a hip fracture over the 16-year period, compared with 32% of women in the lowest quartile of hip bone density.

The difference was “fairly dramatic” he said. Women in the lowest quartile of hip bone density on a single measurement at the start of the study had an immediate increase in risk for hip fracture that continued as far out as 16 years.

“If it's not possible to repeat bone density measurements in 2, 3, or 4 years, the (one) value that you have is still going to be predictive long term,” he said.

There is a growing recognition that T scores shouldn't be used for peripheral measurements. If a patient brings you a printout from a wrist bone density measurement that she got in a pharmacy, use that as an opportunity to talk about bone health and maybe get a more central bone density measurement, he suggested.

SAN FRANCISCO — Measuring bone mineral density in older patients is as justifiable as measuring lipids, Dennis M. Black, Ph.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Lipid testing and treatment for high cholesterol is accepted as an integral part of primary care, but bone densitometry and treatment for low bone density isn't as readily accepted, said Dr. Black, professor of epidemiology and biostatistics at the university.

That's partly because measurements and treatments for osteoporosis came along well after tests and treatments for heart disease and its risk factors, he explained. The ready acceptance of lipid screening compared with bone density screening bothers some osteoporosis experts. “It might be called lipid envy,” he joked.

The value of bone density testing stacks up nicely against the value of lipid testing. Studies have shown that people with cholesterol measurements in the highest quartile have four times the risk for heart disease compared with people whose cholesterol measurements are in the lowest quartile, Dr. Black said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is in the lowest quartile compared with those in the highest quartile.

Heart disease risk increases from about 0.5% in the lowest low-density lipoprotein (LDL) quartile to about 4% in the highest lipid quartile. Hip fracture risk increases from about 0.5% in the highest quartile of hip bone density to about 10% in the quartile with the least hip bone density.

Cost-effectiveness compares well, too, he added. Screening lipid levels in a 52-year-old woman and treating her for an LDL level greater than 160 mg/dL costs about $400,000 per quality-adjusted life-year. Screening bone density in a 65-year-old woman and treating her with bisphosphonates for a T score of −2.5 (suggesting osteoporosis) costs about $30,000 per quality-adjusted life-year, “which is considered cost effective,” Dr. Black said.

The National Osteoporosis Foundation recommends bone mineral density testing for all women aged 65 years and older, and for postmenopausal women with a risk factor for osteoporosis.

The definition of risk factors for osteoporosis is a bit murky. Dr. Black includes postmenopausal women who have a history of fracture after menopause, whose mothers have a history of fracture (especially hip fracture), who take steroids, or who have very low body weight. Very low body weight commonly is considered being below 125 pounds, but that depends somewhat on height, he added.

The U.S. Preventive Services Task Force recommends bone mineral density measurements for all women above age 60. Medicare covers bone density tests for women over age 65.

Dr. Black recently analyzed 16 years of follow-up data on women in the Study of Osteoporotic Fractures and found that a single measurement of hip bone density is a good predictor of fracture risk. In these white women with a mean age of 71 years, 5% of those in the highest quartile of hip bone density developed a hip fracture over the 16-year period, compared with 32% of women in the lowest quartile of hip bone density.

The difference was “fairly dramatic” he said. Women in the lowest quartile of hip bone density on a single measurement at the start of the study had an immediate increase in risk for hip fracture that continued as far out as 16 years.

“If it's not possible to repeat bone density measurements in 2, 3, or 4 years, the (one) value that you have is still going to be predictive long term,” he said.

There is a growing recognition that T scores shouldn't be used for peripheral measurements. If a patient brings you a printout from a wrist bone density measurement that she got in a pharmacy, use that as an opportunity to talk about bone health and maybe get a more central bone density measurement, he suggested.

SAN FRANCISCO — Measuring bone mineral density in older patients is as justifiable as measuring lipids, Dennis M. Black, Ph.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Lipid testing and treatment for high cholesterol is accepted as an integral part of primary care, but bone densitometry and treatment for low bone density isn't as readily accepted, said Dr. Black, professor of epidemiology and biostatistics at the university.

That's partly because measurements and treatments for osteoporosis came along well after tests and treatments for heart disease and its risk factors, he explained. The ready acceptance of lipid screening compared with bone density screening bothers some osteoporosis experts. “It might be called lipid envy,” he joked.

The value of bone density testing stacks up nicely against the value of lipid testing. Studies have shown that people with cholesterol measurements in the highest quartile have four times the risk for heart disease compared with people whose cholesterol measurements are in the lowest quartile, Dr. Black said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is in the lowest quartile compared with those in the highest quartile.

Heart disease risk increases from about 0.5% in the lowest low-density lipoprotein (LDL) quartile to about 4% in the highest lipid quartile. Hip fracture risk increases from about 0.5% in the highest quartile of hip bone density to about 10% in the quartile with the least hip bone density.

Cost-effectiveness compares well, too, he added. Screening lipid levels in a 52-year-old woman and treating her for an LDL level greater than 160 mg/dL costs about $400,000 per quality-adjusted life-year. Screening bone density in a 65-year-old woman and treating her with bisphosphonates for a T score of −2.5 (suggesting osteoporosis) costs about $30,000 per quality-adjusted life-year, “which is considered cost effective,” Dr. Black said.

The National Osteoporosis Foundation recommends bone mineral density testing for all women aged 65 years and older, and for postmenopausal women with a risk factor for osteoporosis.

The definition of risk factors for osteoporosis is a bit murky. Dr. Black includes postmenopausal women who have a history of fracture after menopause, whose mothers have a history of fracture (especially hip fracture), who take steroids, or who have very low body weight. Very low body weight commonly is considered being below 125 pounds, but that depends somewhat on height, he added.

The U.S. Preventive Services Task Force recommends bone mineral density measurements for all women above age 60. Medicare covers bone density tests for women over age 65.

Dr. Black recently analyzed 16 years of follow-up data on women in the Study of Osteoporotic Fractures and found that a single measurement of hip bone density is a good predictor of fracture risk. In these white women with a mean age of 71 years, 5% of those in the highest quartile of hip bone density developed a hip fracture over the 16-year period, compared with 32% of women in the lowest quartile of hip bone density.

The difference was “fairly dramatic” he said. Women in the lowest quartile of hip bone density on a single measurement at the start of the study had an immediate increase in risk for hip fracture that continued as far out as 16 years.

“If it's not possible to repeat bone density measurements in 2, 3, or 4 years, the (one) value that you have is still going to be predictive long term,” he said.

There is a growing recognition that T scores shouldn't be used for peripheral measurements. If a patient brings you a printout from a wrist bone density measurement that she got in a pharmacy, use that as an opportunity to talk about bone health and maybe get a more central bone density measurement, he suggested.

NASHVILLE, TENN. — Physicians may need to rethink their advice to patients to get some casual sun to ensure vitamin D sufficiency, according to new data presented at the annual meeting of the American Society for Bone and Mineral Research.

In a study of young adults in Hawaii, abundant sun exposure did not guarantee adequate serum levels of vitamin D, said Dr. Neil C. Binkley of the osteoporosis clinical center and research program at the University of Wisconsin in Madison.

“This suggests that some individuals—for an unclear reason or reasons—do not achieve a high circulating D₃ concentration despite abundant sun exposure,” he said. “It seems logical that the clinical approach that many of us take to recommend casual sun exposure for patients is certainly not a guarantee of vitamin D adequacy.”

Initially, individuals with abundant sun exposure were studied in order to identify the upper limit of the normal range of 25-hydroxy vitamin D₃ (25[OH]D₃).

The investigators recruited 100 young adults, most of whom were surfers, from the Honolulu area in March 2005.

Participants were required to have had 3 or more hours of sun exposure per day, 5 or more days per week, for the previous 3 months. Information about sun exposure, sunscreen use, and dietary vitamin D intake was obtained by questionnaire. Skin color was measured by reflectance colorimetry.

Forty-one percent of the cohort used no sunscreen. On average, participants were exposed to the sun for about 4 hours per day, or 28 hours weekly.

This estimate included hours exposed to the sun with sunscreen.

As part of the self-questionnaire, respondents were asked to fill in areas of skin coverage on human figures. The researchers were then able to calculate that the group had an average of 10.6 hours per week of whole-body sun exposure.

A group of 174 healthy controls were recruited from the University of Wisconsin between January and April of 2005. No data were obtained from this group regarding sun exposure, sunscreen use, and dietary vitamin D.

The two groups were similar in terms of average age, 24, and average body mass index, 23. There were slightly more men in the Hawaii cohort (67% vs. 46%).

Serum 25(OH)D₃ was measured by a precise high-performance liquid chromatography assay.

Results correlated well with those obtained by tandem mass spectroscopy.

Using a cutoff of 30 ng/mL to define inadequate vitamin D status—a point of some contention among researchers—86% of the Wisconsin cohort was vitamin D inadequate. And “somewhat surprisingly, 51% of the Hawaii cohort was below this arbitrary cutoff.” The mean concentration of serum 25(OH)D₃ was 31.4 ng/mL in the Hawaii cohort, compared with 18.3 ng/mL in the Wisconsin cohort.

The highest levels of 25(OH)D₃ were almost identical in the Hawaii and Wisconsin groups (62.0 ng/mL vs. 62.3 ng/mL). Levels of 25(OH)D₃ in the Hawaii group were unrelated to hours of sun exposure or skin color.

Among those in the Hawaii cohort, the 10 participants with the lowest serum 25(OH)D₃ levels were similar to the rest of the cohort in terms of parathyroid hormone levels, age, body mass index, serum chemistries, multivitamin use, and number of hours of sun exposure without sunscreen.

They did have a lower average number of hours per week of whole-body sun exposure (6 hours).

Serum vitamin D₃ levels were also measured in a random subset of 20 individuals in the Hawaii cohort. “Despite abundant sun exposure, some of these individuals do not maintain a high serum concentration of D₃,” Dr. Binkley said.

The individuals with the highest 25(OH)D₃ levels in both cohorts had levels slightly higher than 60 ng/mL.

This suggests that the upper limit for normal 25(OH)D₃ levels is 60–80 ng/mL, which is consistent with published reports, Dr. Binkley said.

The results are limited by the self-reporting of sun exposure.

NASHVILLE, TENN. — Physicians may need to rethink their advice to patients to get some casual sun to ensure vitamin D sufficiency, according to new data presented at the annual meeting of the American Society for Bone and Mineral Research.

In a study of young adults in Hawaii, abundant sun exposure did not guarantee adequate serum levels of vitamin D, said Dr. Neil C. Binkley of the osteoporosis clinical center and research program at the University of Wisconsin in Madison.

“This suggests that some individuals—for an unclear reason or reasons—do not achieve a high circulating D₃ concentration despite abundant sun exposure,” he said. “It seems logical that the clinical approach that many of us take to recommend casual sun exposure for patients is certainly not a guarantee of vitamin D adequacy.”

Initially, individuals with abundant sun exposure were studied in order to identify the upper limit of the normal range of 25-hydroxy vitamin D₃ (25[OH]D₃).

The investigators recruited 100 young adults, most of whom were surfers, from the Honolulu area in March 2005.

Participants were required to have had 3 or more hours of sun exposure per day, 5 or more days per week, for the previous 3 months. Information about sun exposure, sunscreen use, and dietary vitamin D intake was obtained by questionnaire. Skin color was measured by reflectance colorimetry.

Forty-one percent of the cohort used no sunscreen. On average, participants were exposed to the sun for about 4 hours per day, or 28 hours weekly.

This estimate included hours exposed to the sun with sunscreen.

As part of the self-questionnaire, respondents were asked to fill in areas of skin coverage on human figures. The researchers were then able to calculate that the group had an average of 10.6 hours per week of whole-body sun exposure.

A group of 174 healthy controls were recruited from the University of Wisconsin between January and April of 2005. No data were obtained from this group regarding sun exposure, sunscreen use, and dietary vitamin D.

The two groups were similar in terms of average age, 24, and average body mass index, 23. There were slightly more men in the Hawaii cohort (67% vs. 46%).

Serum 25(OH)D₃ was measured by a precise high-performance liquid chromatography assay.

Results correlated well with those obtained by tandem mass spectroscopy.

Using a cutoff of 30 ng/mL to define inadequate vitamin D status—a point of some contention among researchers—86% of the Wisconsin cohort was vitamin D inadequate. And “somewhat surprisingly, 51% of the Hawaii cohort was below this arbitrary cutoff.” The mean concentration of serum 25(OH)D₃ was 31.4 ng/mL in the Hawaii cohort, compared with 18.3 ng/mL in the Wisconsin cohort.

The highest levels of 25(OH)D₃ were almost identical in the Hawaii and Wisconsin groups (62.0 ng/mL vs. 62.3 ng/mL). Levels of 25(OH)D₃ in the Hawaii group were unrelated to hours of sun exposure or skin color.

Among those in the Hawaii cohort, the 10 participants with the lowest serum 25(OH)D₃ levels were similar to the rest of the cohort in terms of parathyroid hormone levels, age, body mass index, serum chemistries, multivitamin use, and number of hours of sun exposure without sunscreen.

They did have a lower average number of hours per week of whole-body sun exposure (6 hours).

Serum vitamin D₃ levels were also measured in a random subset of 20 individuals in the Hawaii cohort. “Despite abundant sun exposure, some of these individuals do not maintain a high serum concentration of D₃,” Dr. Binkley said.

The individuals with the highest 25(OH)D₃ levels in both cohorts had levels slightly higher than 60 ng/mL.

This suggests that the upper limit for normal 25(OH)D₃ levels is 60–80 ng/mL, which is consistent with published reports, Dr. Binkley said.

The results are limited by the self-reporting of sun exposure.

NASHVILLE, TENN. — Physicians may need to rethink their advice to patients to get some casual sun to ensure vitamin D sufficiency, according to new data presented at the annual meeting of the American Society for Bone and Mineral Research.

In a study of young adults in Hawaii, abundant sun exposure did not guarantee adequate serum levels of vitamin D, said Dr. Neil C. Binkley of the osteoporosis clinical center and research program at the University of Wisconsin in Madison.

“This suggests that some individuals—for an unclear reason or reasons—do not achieve a high circulating D₃ concentration despite abundant sun exposure,” he said. “It seems logical that the clinical approach that many of us take to recommend casual sun exposure for patients is certainly not a guarantee of vitamin D adequacy.”

Initially, individuals with abundant sun exposure were studied in order to identify the upper limit of the normal range of 25-hydroxy vitamin D₃ (25[OH]D₃).

The investigators recruited 100 young adults, most of whom were surfers, from the Honolulu area in March 2005.

Participants were required to have had 3 or more hours of sun exposure per day, 5 or more days per week, for the previous 3 months. Information about sun exposure, sunscreen use, and dietary vitamin D intake was obtained by questionnaire. Skin color was measured by reflectance colorimetry.

Forty-one percent of the cohort used no sunscreen. On average, participants were exposed to the sun for about 4 hours per day, or 28 hours weekly.

This estimate included hours exposed to the sun with sunscreen.

As part of the self-questionnaire, respondents were asked to fill in areas of skin coverage on human figures. The researchers were then able to calculate that the group had an average of 10.6 hours per week of whole-body sun exposure.

A group of 174 healthy controls were recruited from the University of Wisconsin between January and April of 2005. No data were obtained from this group regarding sun exposure, sunscreen use, and dietary vitamin D.

The two groups were similar in terms of average age, 24, and average body mass index, 23. There were slightly more men in the Hawaii cohort (67% vs. 46%).

Serum 25(OH)D₃ was measured by a precise high-performance liquid chromatography assay.

Results correlated well with those obtained by tandem mass spectroscopy.

Using a cutoff of 30 ng/mL to define inadequate vitamin D status—a point of some contention among researchers—86% of the Wisconsin cohort was vitamin D inadequate. And “somewhat surprisingly, 51% of the Hawaii cohort was below this arbitrary cutoff.” The mean concentration of serum 25(OH)D₃ was 31.4 ng/mL in the Hawaii cohort, compared with 18.3 ng/mL in the Wisconsin cohort.

The highest levels of 25(OH)D₃ were almost identical in the Hawaii and Wisconsin groups (62.0 ng/mL vs. 62.3 ng/mL). Levels of 25(OH)D₃ in the Hawaii group were unrelated to hours of sun exposure or skin color.

Among those in the Hawaii cohort, the 10 participants with the lowest serum 25(OH)D₃ levels were similar to the rest of the cohort in terms of parathyroid hormone levels, age, body mass index, serum chemistries, multivitamin use, and number of hours of sun exposure without sunscreen.

They did have a lower average number of hours per week of whole-body sun exposure (6 hours).

Serum vitamin D₃ levels were also measured in a random subset of 20 individuals in the Hawaii cohort. “Despite abundant sun exposure, some of these individuals do not maintain a high serum concentration of D₃,” Dr. Binkley said.

The individuals with the highest 25(OH)D₃ levels in both cohorts had levels slightly higher than 60 ng/mL.

This suggests that the upper limit for normal 25(OH)D₃ levels is 60–80 ng/mL, which is consistent with published reports, Dr. Binkley said.

The results are limited by the self-reporting of sun exposure.

The bisphosphonate risedronate significantly reduced the risk of hip fracture in elderly men with a history of stroke, in the first randomized, double-blind study on this topic.

Risedronate sodium, an inhibitor of bone resorption, previously was shown to decrease the risk of nonvertebral fractures in postmenopausal women with osteoporosis and of hip fractures in women who had a stroke.

The current study randomized 280 consecutive ambulatory men aged 65 years or older with a previous stroke to a daily dosage of 2.5 mg risedronate or placebo for 18 months. By the study's end, 10 patients in the placebo group and 2 in the risedronate group had sustained hip fractures, representing an 80% reduction in risk of fracture in the risedronate group, reported Dr. Yoshihiro Sato of Mitate Hospital, Tagawa, Japan, and his associates (Arch. Intern. Med. 2005;165:1743–8).

The investigators estimated that 16 elderly men who had previous strokes would need to be treated with risedronate to prevent one hip fracture.

All of the hip fractures were on the patient's hemiplegic side. In addition to hip fractures, wrist or ankle fractures occurred in two patients in the risedronate group, and six patients in the placebo group sustained other fractures—two at the proximal femur, two at the ribs, one at the proximal humerus, and one at the pelvis.

Bone mineral density on the hemiplegic side increased by 2.5% in men in the risedronate group, compared with baseline measurements, but decreased by 3.5% in men in the placebo group, compared with baseline, a significant difference.

On the nonhemiplegic side, bone density increased by more than 3% in the risedronate group and decreased by 2% in the placebo group. Bone density was significantly lower on the hemiplegic side in both groups. A key marker of bone resorption—urinary deoxypyridinoline—decreased by 59% in the risedronate group and by 37% in the placebo group. Bone resorption typically increases during the first year after a stroke in both men and women, studies have shown.

Patients in the current study were advised to take risedronate with water 30–60 minutes before breakfast and not to take any other drugs that could affect bone or calcium metabolism. Patients were asked to return pills not taken, which were counted to check adherence to therapy. A single physician who was blinded to treatment assignment did the follow-up assessments of all patients, evaluating them every 4 weeks for falls or possible hip fractures and performing hematologic and biochemical tests.

Six patients in the risedronate group and seven in the placebo group dropped out of the study or were lost to follow-up, illness, or death.

The bisphosphonate risedronate significantly reduced the risk of hip fracture in elderly men with a history of stroke, in the first randomized, double-blind study on this topic.

Risedronate sodium, an inhibitor of bone resorption, previously was shown to decrease the risk of nonvertebral fractures in postmenopausal women with osteoporosis and of hip fractures in women who had a stroke.

The current study randomized 280 consecutive ambulatory men aged 65 years or older with a previous stroke to a daily dosage of 2.5 mg risedronate or placebo for 18 months. By the study's end, 10 patients in the placebo group and 2 in the risedronate group had sustained hip fractures, representing an 80% reduction in risk of fracture in the risedronate group, reported Dr. Yoshihiro Sato of Mitate Hospital, Tagawa, Japan, and his associates (Arch. Intern. Med. 2005;165:1743–8).

The investigators estimated that 16 elderly men who had previous strokes would need to be treated with risedronate to prevent one hip fracture.

All of the hip fractures were on the patient's hemiplegic side. In addition to hip fractures, wrist or ankle fractures occurred in two patients in the risedronate group, and six patients in the placebo group sustained other fractures—two at the proximal femur, two at the ribs, one at the proximal humerus, and one at the pelvis.

Bone mineral density on the hemiplegic side increased by 2.5% in men in the risedronate group, compared with baseline measurements, but decreased by 3.5% in men in the placebo group, compared with baseline, a significant difference.

On the nonhemiplegic side, bone density increased by more than 3% in the risedronate group and decreased by 2% in the placebo group. Bone density was significantly lower on the hemiplegic side in both groups. A key marker of bone resorption—urinary deoxypyridinoline—decreased by 59% in the risedronate group and by 37% in the placebo group. Bone resorption typically increases during the first year after a stroke in both men and women, studies have shown.

Patients in the current study were advised to take risedronate with water 30–60 minutes before breakfast and not to take any other drugs that could affect bone or calcium metabolism. Patients were asked to return pills not taken, which were counted to check adherence to therapy. A single physician who was blinded to treatment assignment did the follow-up assessments of all patients, evaluating them every 4 weeks for falls or possible hip fractures and performing hematologic and biochemical tests.

Six patients in the risedronate group and seven in the placebo group dropped out of the study or were lost to follow-up, illness, or death.

The bisphosphonate risedronate significantly reduced the risk of hip fracture in elderly men with a history of stroke, in the first randomized, double-blind study on this topic.

Risedronate sodium, an inhibitor of bone resorption, previously was shown to decrease the risk of nonvertebral fractures in postmenopausal women with osteoporosis and of hip fractures in women who had a stroke.

The current study randomized 280 consecutive ambulatory men aged 65 years or older with a previous stroke to a daily dosage of 2.5 mg risedronate or placebo for 18 months. By the study's end, 10 patients in the placebo group and 2 in the risedronate group had sustained hip fractures, representing an 80% reduction in risk of fracture in the risedronate group, reported Dr. Yoshihiro Sato of Mitate Hospital, Tagawa, Japan, and his associates (Arch. Intern. Med. 2005;165:1743–8).

The investigators estimated that 16 elderly men who had previous strokes would need to be treated with risedronate to prevent one hip fracture.

All of the hip fractures were on the patient's hemiplegic side. In addition to hip fractures, wrist or ankle fractures occurred in two patients in the risedronate group, and six patients in the placebo group sustained other fractures—two at the proximal femur, two at the ribs, one at the proximal humerus, and one at the pelvis.

Bone mineral density on the hemiplegic side increased by 2.5% in men in the risedronate group, compared with baseline measurements, but decreased by 3.5% in men in the placebo group, compared with baseline, a significant difference.

On the nonhemiplegic side, bone density increased by more than 3% in the risedronate group and decreased by 2% in the placebo group. Bone density was significantly lower on the hemiplegic side in both groups. A key marker of bone resorption—urinary deoxypyridinoline—decreased by 59% in the risedronate group and by 37% in the placebo group. Bone resorption typically increases during the first year after a stroke in both men and women, studies have shown.

Patients in the current study were advised to take risedronate with water 30–60 minutes before breakfast and not to take any other drugs that could affect bone or calcium metabolism. Patients were asked to return pills not taken, which were counted to check adherence to therapy. A single physician who was blinded to treatment assignment did the follow-up assessments of all patients, evaluating them every 4 weeks for falls or possible hip fractures and performing hematologic and biochemical tests.

Six patients in the risedronate group and seven in the placebo group dropped out of the study or were lost to follow-up, illness, or death.