Barbara J. Rutledge

Surgical treatment of mild obstructive sleep apnea in school-aged children diagnosed with attention-deficit/hyperactivity disorder and mild obstructive sleep apnea resulted in big improvements in ADHD symptoms, compared with those treated with methylphenidate alone, investigators reported.

“Recognition and surgical treatment of underlying mild sleep-disordered breathing in children with ADHD may prevent unnecessary long-term methylphenidate usage and the potential side effects associated with drug intake,” Dr. Yu-Shu Huang, of Chang Gung Memorial University Hospital, Taipei, Taiwan, and colleagues wrote (Sleep Med. 2007;8:18–30).

Dr. Huang and colleagues examined the effect of three treatment options on 66 children with ADHD and mild obstructive sleep apnea confirmed by polysomnography treatment with methylphenidate, under supervision of the child's psychiatrist; systematic adenotonsillectomy, in children with adenotonsil hypertrophy confirmed by a pediatric otolaryngologist; or a wait-and-see approach, with regular follow-up but no treatment.

The study population was recruited from among school children, aged 6–12 years, who were referred to a child psychiatry clinic for behavioral problems suggestive of ADHD. All children received a thorough clinical evaluation, and an ear, nose, and throat specialist performed an otolaryngolic examination. Children were given comprehensive neuropsychological tests, including the Test of Variables of Attention (TOVA), to evaluate AHDH. Parents completed questionnaires concerning their children's behavior (Child Behavior Checklist) and quality of life in children with obstructive sleep disorders (OSA-18).

All 66 children with ADHD had apnea-hypopnea index scores between 1 and 5 (mild apnea) before treatment. Twenty-seven children received methylphenidate, 25 were given an adenotonsillectomy, and 14 had no treatment.

Both the adenotonsillectomy group and the methylphenidate group had far better posttreatment scores on neuropsychological assessments of ADHD than did the no-treatment group or the control group. “The results support the need to treat OSA first when identified in the presence of an AHDH clinical presentation,” Dr. Huang wrote.

Surgical treatment of mild obstructive sleep apnea in school-aged children diagnosed with attention-deficit/hyperactivity disorder and mild obstructive sleep apnea resulted in big improvements in ADHD symptoms, compared with those treated with methylphenidate alone, investigators reported.

“Recognition and surgical treatment of underlying mild sleep-disordered breathing in children with ADHD may prevent unnecessary long-term methylphenidate usage and the potential side effects associated with drug intake,” Dr. Yu-Shu Huang, of Chang Gung Memorial University Hospital, Taipei, Taiwan, and colleagues wrote (Sleep Med. 2007;8:18–30).

Dr. Huang and colleagues examined the effect of three treatment options on 66 children with ADHD and mild obstructive sleep apnea confirmed by polysomnography treatment with methylphenidate, under supervision of the child's psychiatrist; systematic adenotonsillectomy, in children with adenotonsil hypertrophy confirmed by a pediatric otolaryngologist; or a wait-and-see approach, with regular follow-up but no treatment.

The study population was recruited from among school children, aged 6–12 years, who were referred to a child psychiatry clinic for behavioral problems suggestive of ADHD. All children received a thorough clinical evaluation, and an ear, nose, and throat specialist performed an otolaryngolic examination. Children were given comprehensive neuropsychological tests, including the Test of Variables of Attention (TOVA), to evaluate AHDH. Parents completed questionnaires concerning their children's behavior (Child Behavior Checklist) and quality of life in children with obstructive sleep disorders (OSA-18).

All 66 children with ADHD had apnea-hypopnea index scores between 1 and 5 (mild apnea) before treatment. Twenty-seven children received methylphenidate, 25 were given an adenotonsillectomy, and 14 had no treatment.

Both the adenotonsillectomy group and the methylphenidate group had far better posttreatment scores on neuropsychological assessments of ADHD than did the no-treatment group or the control group. “The results support the need to treat OSA first when identified in the presence of an AHDH clinical presentation,” Dr. Huang wrote.

Surgical treatment of mild obstructive sleep apnea in school-aged children diagnosed with attention-deficit/hyperactivity disorder and mild obstructive sleep apnea resulted in big improvements in ADHD symptoms, compared with those treated with methylphenidate alone, investigators reported.

“Recognition and surgical treatment of underlying mild sleep-disordered breathing in children with ADHD may prevent unnecessary long-term methylphenidate usage and the potential side effects associated with drug intake,” Dr. Yu-Shu Huang, of Chang Gung Memorial University Hospital, Taipei, Taiwan, and colleagues wrote (Sleep Med. 2007;8:18–30).

Dr. Huang and colleagues examined the effect of three treatment options on 66 children with ADHD and mild obstructive sleep apnea confirmed by polysomnography treatment with methylphenidate, under supervision of the child's psychiatrist; systematic adenotonsillectomy, in children with adenotonsil hypertrophy confirmed by a pediatric otolaryngologist; or a wait-and-see approach, with regular follow-up but no treatment.

The study population was recruited from among school children, aged 6–12 years, who were referred to a child psychiatry clinic for behavioral problems suggestive of ADHD. All children received a thorough clinical evaluation, and an ear, nose, and throat specialist performed an otolaryngolic examination. Children were given comprehensive neuropsychological tests, including the Test of Variables of Attention (TOVA), to evaluate AHDH. Parents completed questionnaires concerning their children's behavior (Child Behavior Checklist) and quality of life in children with obstructive sleep disorders (OSA-18).

All 66 children with ADHD had apnea-hypopnea index scores between 1 and 5 (mild apnea) before treatment. Twenty-seven children received methylphenidate, 25 were given an adenotonsillectomy, and 14 had no treatment.

Both the adenotonsillectomy group and the methylphenidate group had far better posttreatment scores on neuropsychological assessments of ADHD than did the no-treatment group or the control group. “The results support the need to treat OSA first when identified in the presence of an AHDH clinical presentation,” Dr. Huang wrote.

TAMPA — Diagnosis of osteoporosis in patients with advanced chronic kidney disease cannot be accomplished simply on the basis of T score or bone fragility, Dr. Paul Miller said at the annual meeting of the International Society for Clinical Densitometry.

“People with more severe chronic kidney disease can have a whole host of metabolic bone diseases that mimic osteoporosis, either by bone density criteria or fractures, and yet may not be osteoporosis,” said Dr. Miller, medical director of a bone research center in Lakewood, Colo.

Patients with advanced chronic kidney disease (CKD) are at increased risk for osteoporosis, resulting from a variety of factors. Chronic heparin use and steroid use may be risk factors for patients on dialysis. In transplant patients, the use of calcineurin inhibitors can cause high bone turnover, increasing bone fragility.

Hypogonadism, hyperprolacti- nemia, poor nutrition, vitamin D deficiency, and hyperparathyroidism are other osteoporosis risk factors in CKD patients. They may be more likely than others to develop forms of osteoporosis that could be treated effectively by bisphosphonates, said Dr. Miller.

However, CKD patients are also at risk for other bone metabolic diseases, including osteitis fibrosa cystica, osteomalacia, and adynamic bone disease. Bisphosphonates may be contraindicated in patients with severe adynamic bone disease or osteomalacia. “We don't have data, but it doesn't make sense to try to use drugs that reduce bone turnover to try to improve bone strength when you already have a low bone-turnover disease such as adynamic bone disease or osteomalacia,” he said.

Renal impairment is associated with increased fracture risk, even in patients without severe renal disease. A recent analysis of data from the Study of Osteoporotic Fractures cohort showed that age-related reduction in renal function that causes mild to moderate renal impairment is associated with increased hip fracture risk in older women (Arch. Intern. Med. 2007;167:133–9).

Diagnosis of osteoporosis in CKD patients must exclude other causes of low bone mineral density (BMD) or fragility fractures. The latter can be seen in transplant recipients and in patients with severe hyperparathyroidism, adynamic bone disease, or osteomalacia.

Severe adynamic bone disease and osteomalacia are considered to have low prevalence in CKD before stage 5 disease, according to Dr. Miller, and mild secondary hyperparathyroidism in that patient population does not cause fractures. Therefore, if the biochemical profile does not suggest severe hyperparathyroidism or other renal bone disease, low T scores based on the World Health Organization criteria or fragility fractures should be sufficient for the diagnosis of osteoporosis in patients with stage 1–4 CKD, he said.

For patients with stage 5 CKD who have low BMD or fragility fractures, a double tetracycline-labeled bone biopsy is necessary to rule out other causes of metabolic bone disease and confirm a diagnosis of osteoporosis.

Caution is advised for bisphosphonate treatment of advanced CKD patients, said Dr. Miller. Labeling recommendations for bisphosphonates exclude patients with creatinine clearance under 35 mL/min, largely because of a lack of data about bisphosphonates in CKD patients.

TAMPA — Diagnosis of osteoporosis in patients with advanced chronic kidney disease cannot be accomplished simply on the basis of T score or bone fragility, Dr. Paul Miller said at the annual meeting of the International Society for Clinical Densitometry.

“People with more severe chronic kidney disease can have a whole host of metabolic bone diseases that mimic osteoporosis, either by bone density criteria or fractures, and yet may not be osteoporosis,” said Dr. Miller, medical director of a bone research center in Lakewood, Colo.

Patients with advanced chronic kidney disease (CKD) are at increased risk for osteoporosis, resulting from a variety of factors. Chronic heparin use and steroid use may be risk factors for patients on dialysis. In transplant patients, the use of calcineurin inhibitors can cause high bone turnover, increasing bone fragility.

Hypogonadism, hyperprolacti- nemia, poor nutrition, vitamin D deficiency, and hyperparathyroidism are other osteoporosis risk factors in CKD patients. They may be more likely than others to develop forms of osteoporosis that could be treated effectively by bisphosphonates, said Dr. Miller.

However, CKD patients are also at risk for other bone metabolic diseases, including osteitis fibrosa cystica, osteomalacia, and adynamic bone disease. Bisphosphonates may be contraindicated in patients with severe adynamic bone disease or osteomalacia. “We don't have data, but it doesn't make sense to try to use drugs that reduce bone turnover to try to improve bone strength when you already have a low bone-turnover disease such as adynamic bone disease or osteomalacia,” he said.

Renal impairment is associated with increased fracture risk, even in patients without severe renal disease. A recent analysis of data from the Study of Osteoporotic Fractures cohort showed that age-related reduction in renal function that causes mild to moderate renal impairment is associated with increased hip fracture risk in older women (Arch. Intern. Med. 2007;167:133–9).

Diagnosis of osteoporosis in CKD patients must exclude other causes of low bone mineral density (BMD) or fragility fractures. The latter can be seen in transplant recipients and in patients with severe hyperparathyroidism, adynamic bone disease, or osteomalacia.

Severe adynamic bone disease and osteomalacia are considered to have low prevalence in CKD before stage 5 disease, according to Dr. Miller, and mild secondary hyperparathyroidism in that patient population does not cause fractures. Therefore, if the biochemical profile does not suggest severe hyperparathyroidism or other renal bone disease, low T scores based on the World Health Organization criteria or fragility fractures should be sufficient for the diagnosis of osteoporosis in patients with stage 1–4 CKD, he said.

For patients with stage 5 CKD who have low BMD or fragility fractures, a double tetracycline-labeled bone biopsy is necessary to rule out other causes of metabolic bone disease and confirm a diagnosis of osteoporosis.

Caution is advised for bisphosphonate treatment of advanced CKD patients, said Dr. Miller. Labeling recommendations for bisphosphonates exclude patients with creatinine clearance under 35 mL/min, largely because of a lack of data about bisphosphonates in CKD patients.

TAMPA — Diagnosis of osteoporosis in patients with advanced chronic kidney disease cannot be accomplished simply on the basis of T score or bone fragility, Dr. Paul Miller said at the annual meeting of the International Society for Clinical Densitometry.

“People with more severe chronic kidney disease can have a whole host of metabolic bone diseases that mimic osteoporosis, either by bone density criteria or fractures, and yet may not be osteoporosis,” said Dr. Miller, medical director of a bone research center in Lakewood, Colo.

Patients with advanced chronic kidney disease (CKD) are at increased risk for osteoporosis, resulting from a variety of factors. Chronic heparin use and steroid use may be risk factors for patients on dialysis. In transplant patients, the use of calcineurin inhibitors can cause high bone turnover, increasing bone fragility.

Hypogonadism, hyperprolacti- nemia, poor nutrition, vitamin D deficiency, and hyperparathyroidism are other osteoporosis risk factors in CKD patients. They may be more likely than others to develop forms of osteoporosis that could be treated effectively by bisphosphonates, said Dr. Miller.

However, CKD patients are also at risk for other bone metabolic diseases, including osteitis fibrosa cystica, osteomalacia, and adynamic bone disease. Bisphosphonates may be contraindicated in patients with severe adynamic bone disease or osteomalacia. “We don't have data, but it doesn't make sense to try to use drugs that reduce bone turnover to try to improve bone strength when you already have a low bone-turnover disease such as adynamic bone disease or osteomalacia,” he said.

Renal impairment is associated with increased fracture risk, even in patients without severe renal disease. A recent analysis of data from the Study of Osteoporotic Fractures cohort showed that age-related reduction in renal function that causes mild to moderate renal impairment is associated with increased hip fracture risk in older women (Arch. Intern. Med. 2007;167:133–9).

Diagnosis of osteoporosis in CKD patients must exclude other causes of low bone mineral density (BMD) or fragility fractures. The latter can be seen in transplant recipients and in patients with severe hyperparathyroidism, adynamic bone disease, or osteomalacia.

Severe adynamic bone disease and osteomalacia are considered to have low prevalence in CKD before stage 5 disease, according to Dr. Miller, and mild secondary hyperparathyroidism in that patient population does not cause fractures. Therefore, if the biochemical profile does not suggest severe hyperparathyroidism or other renal bone disease, low T scores based on the World Health Organization criteria or fragility fractures should be sufficient for the diagnosis of osteoporosis in patients with stage 1–4 CKD, he said.

For patients with stage 5 CKD who have low BMD or fragility fractures, a double tetracycline-labeled bone biopsy is necessary to rule out other causes of metabolic bone disease and confirm a diagnosis of osteoporosis.

Caution is advised for bisphosphonate treatment of advanced CKD patients, said Dr. Miller. Labeling recommendations for bisphosphonates exclude patients with creatinine clearance under 35 mL/min, largely because of a lack of data about bisphosphonates in CKD patients.

TAMPA — Anorexia nervosa reduces bone mass and puts young women at risk for early onset of osteoporosis, just at the time when they should be building peak bone mass, Dr. Steven Crawford said at the annual meeting of the International Society for Clinical Densitometry.

Anorexia nervosa is one of the most common psychiatric diagnoses in adolescent women, with the age of onset showing bimodal peaks at ages 14 and 18 years. In addition to loss of bone density, patients can suffer cardiovascular problems, muscle loss and weakness, severe dehydration, anemia, and leukopenia. Female anorexic patients are amenorrheic. Anorexia nervosa leads to a sevenfold increase in fracture risk. Of adult women with anorexia nervosa, 38% have osteoporosis, and 50% have a bone mineral density (BMD) level below the fracture threshold.

The extent of bone damage is directly affected by the severity of malnutrition and the disease duration. Consequences are more severe when disease onset occurs during the time of peak bone development. About 60% of total bone mass is attained in the growth spurt that normally occurs in adolescence, and skeletal growth essentially is complete by age 18.

“Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life, even when the duration of illness is comparable,” said Dr. Crawford, a clinical psychiatrist at the Center for Eating Disorders, Sheppard Pratt Health System, Baltimore.

Pathophysiology of low bone density in anorexia nervosa results from multiple factors, including undernutrition, hypogonadism, altered levels of bone-essential hormones and growth factors, excessive exercise, and hypercortisolism. Undernutrition in anorexia nervosa leads to decreased levels of the sex hormones that are critical for bone development.

Levels of insulinlike growth factor-I (IGF-I) and growth hormone normally increase during puberty, and stimulate bone anabolism. In anorexic patients, IGF-I levels decrease, and patients acquire growth hormone resistance. Lack of calcium may prevent bone remodeling normally stimulated by exercise, and hypogonadism may impair the function of osteocytes that normally are activated by exercise.

Low BMD occurs at all skeletal sites in anorexic patients, affecting both trabecular and cortical bone. The spine is more likely to be affected than the hip.

In addition to decreased BMD, another factor that contributes to bone fragility is decreased bone size. Patients with anorexia nervosa develop smaller bones in the vertebral body and femoral neck, compared with normal patients. Osteoporosis contributes to stress fractures in weight-bearing bones and vertebral fractures, leading to chronic back pain and reduced height.

Dr. Crawford recommends a routine bone density scan in all patients with anorexia nervosa at disease onset and at least every 2 years thereafter. Restoration of normal weight can improve BMD in anorexic patients, but bone loss may continue, with bone restoration taking at least 21 months.

Bisphosphonates are not approved for treatment of premenopausal women. Moreover, the increased bone turnover that occurs normally during adolescence makes the use of bisphosphonates especially controversial for patients in that age group.

Although adequate calcium and vitamin D intake should be provided to patients with anorexia nervosa, such supplementation does not increase BMD in anorexic patients. Some evidence suggests that a combination of twice-daily IGF-I administration and estrogen-progesterone treatment may be effective in increasing BMD in anorexic women. Androgen-replacement studies have yielded conflicting results.

Usually, patients with osteoporosis are advised to engage in weight-bearing exercise. But for anorexic patients, the potential benefits might be offset by the risk of fractures, delayed weight gain, and exercise-induced amenorrhea.

'Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life.' DR. CRAWFORD

TAMPA — Anorexia nervosa reduces bone mass and puts young women at risk for early onset of osteoporosis, just at the time when they should be building peak bone mass, Dr. Steven Crawford said at the annual meeting of the International Society for Clinical Densitometry.

Anorexia nervosa is one of the most common psychiatric diagnoses in adolescent women, with the age of onset showing bimodal peaks at ages 14 and 18 years. In addition to loss of bone density, patients can suffer cardiovascular problems, muscle loss and weakness, severe dehydration, anemia, and leukopenia. Female anorexic patients are amenorrheic. Anorexia nervosa leads to a sevenfold increase in fracture risk. Of adult women with anorexia nervosa, 38% have osteoporosis, and 50% have a bone mineral density (BMD) level below the fracture threshold.

The extent of bone damage is directly affected by the severity of malnutrition and the disease duration. Consequences are more severe when disease onset occurs during the time of peak bone development. About 60% of total bone mass is attained in the growth spurt that normally occurs in adolescence, and skeletal growth essentially is complete by age 18.

“Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life, even when the duration of illness is comparable,” said Dr. Crawford, a clinical psychiatrist at the Center for Eating Disorders, Sheppard Pratt Health System, Baltimore.

Pathophysiology of low bone density in anorexia nervosa results from multiple factors, including undernutrition, hypogonadism, altered levels of bone-essential hormones and growth factors, excessive exercise, and hypercortisolism. Undernutrition in anorexia nervosa leads to decreased levels of the sex hormones that are critical for bone development.

Levels of insulinlike growth factor-I (IGF-I) and growth hormone normally increase during puberty, and stimulate bone anabolism. In anorexic patients, IGF-I levels decrease, and patients acquire growth hormone resistance. Lack of calcium may prevent bone remodeling normally stimulated by exercise, and hypogonadism may impair the function of osteocytes that normally are activated by exercise.

Low BMD occurs at all skeletal sites in anorexic patients, affecting both trabecular and cortical bone. The spine is more likely to be affected than the hip.

In addition to decreased BMD, another factor that contributes to bone fragility is decreased bone size. Patients with anorexia nervosa develop smaller bones in the vertebral body and femoral neck, compared with normal patients. Osteoporosis contributes to stress fractures in weight-bearing bones and vertebral fractures, leading to chronic back pain and reduced height.

Dr. Crawford recommends a routine bone density scan in all patients with anorexia nervosa at disease onset and at least every 2 years thereafter. Restoration of normal weight can improve BMD in anorexic patients, but bone loss may continue, with bone restoration taking at least 21 months.

Bisphosphonates are not approved for treatment of premenopausal women. Moreover, the increased bone turnover that occurs normally during adolescence makes the use of bisphosphonates especially controversial for patients in that age group.

Although adequate calcium and vitamin D intake should be provided to patients with anorexia nervosa, such supplementation does not increase BMD in anorexic patients. Some evidence suggests that a combination of twice-daily IGF-I administration and estrogen-progesterone treatment may be effective in increasing BMD in anorexic women. Androgen-replacement studies have yielded conflicting results.

Usually, patients with osteoporosis are advised to engage in weight-bearing exercise. But for anorexic patients, the potential benefits might be offset by the risk of fractures, delayed weight gain, and exercise-induced amenorrhea.

'Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life.' DR. CRAWFORD

TAMPA — Anorexia nervosa reduces bone mass and puts young women at risk for early onset of osteoporosis, just at the time when they should be building peak bone mass, Dr. Steven Crawford said at the annual meeting of the International Society for Clinical Densitometry.

Anorexia nervosa is one of the most common psychiatric diagnoses in adolescent women, with the age of onset showing bimodal peaks at ages 14 and 18 years. In addition to loss of bone density, patients can suffer cardiovascular problems, muscle loss and weakness, severe dehydration, anemia, and leukopenia. Female anorexic patients are amenorrheic. Anorexia nervosa leads to a sevenfold increase in fracture risk. Of adult women with anorexia nervosa, 38% have osteoporosis, and 50% have a bone mineral density (BMD) level below the fracture threshold.

The extent of bone damage is directly affected by the severity of malnutrition and the disease duration. Consequences are more severe when disease onset occurs during the time of peak bone development. About 60% of total bone mass is attained in the growth spurt that normally occurs in adolescence, and skeletal growth essentially is complete by age 18.

“Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life, even when the duration of illness is comparable,” said Dr. Crawford, a clinical psychiatrist at the Center for Eating Disorders, Sheppard Pratt Health System, Baltimore.

Pathophysiology of low bone density in anorexia nervosa results from multiple factors, including undernutrition, hypogonadism, altered levels of bone-essential hormones and growth factors, excessive exercise, and hypercortisolism. Undernutrition in anorexia nervosa leads to decreased levels of the sex hormones that are critical for bone development.

Levels of insulinlike growth factor-I (IGF-I) and growth hormone normally increase during puberty, and stimulate bone anabolism. In anorexic patients, IGF-I levels decrease, and patients acquire growth hormone resistance. Lack of calcium may prevent bone remodeling normally stimulated by exercise, and hypogonadism may impair the function of osteocytes that normally are activated by exercise.

Low BMD occurs at all skeletal sites in anorexic patients, affecting both trabecular and cortical bone. The spine is more likely to be affected than the hip.

In addition to decreased BMD, another factor that contributes to bone fragility is decreased bone size. Patients with anorexia nervosa develop smaller bones in the vertebral body and femoral neck, compared with normal patients. Osteoporosis contributes to stress fractures in weight-bearing bones and vertebral fractures, leading to chronic back pain and reduced height.

Dr. Crawford recommends a routine bone density scan in all patients with anorexia nervosa at disease onset and at least every 2 years thereafter. Restoration of normal weight can improve BMD in anorexic patients, but bone loss may continue, with bone restoration taking at least 21 months.

Bisphosphonates are not approved for treatment of premenopausal women. Moreover, the increased bone turnover that occurs normally during adolescence makes the use of bisphosphonates especially controversial for patients in that age group.

Although adequate calcium and vitamin D intake should be provided to patients with anorexia nervosa, such supplementation does not increase BMD in anorexic patients. Some evidence suggests that a combination of twice-daily IGF-I administration and estrogen-progesterone treatment may be effective in increasing BMD in anorexic women. Androgen-replacement studies have yielded conflicting results.

Usually, patients with osteoporosis are advised to engage in weight-bearing exercise. But for anorexic patients, the potential benefits might be offset by the risk of fractures, delayed weight gain, and exercise-induced amenorrhea.

'Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life.' DR. CRAWFORD

Timothy F. Kirn of the Sacramento Bureau contributed to this report.

Updated guidelines slated for release this year should make it easier for physicians and patients to manage osteoporosis and make informed treatment decisions, according to Dr. Bess Dawson-Hughes, director of the bone metabolism laboratory at Tufts University, Boston.

“We are under increasing pressure to develop ways to better identify those patients who will benefit most from treatment,” Dr. Dawson-Hughes said at the annual meeting of the International Society for Clinical Densitometry in Tampa.

The National Osteoporosis Foundation (NOF) is revising its Physician's Guide to Prevention and Treatment of Osteoporosis to incorporate a new World Health Organization (WHO) algorithm that evaluates absolute fracture risk.

Absolute fracture risk is easier for patients to understand than are T scores or z scores, so the phrase “Know your fracture risk” will replace “Know your T score” as the message for patients. The use of absolute fracture risk should allow patients to consider their osteoporosis risk in the context of other chronic disease risks, and to facilitate better decision making concerning osteoporosis treatment, she said.

The need for the updated algorithm is largely to expand treatment to those women who do not clearly have osteoporosis and for whom there has not been a consensus about when to treat—that is, primarily those postmenopausal women whose dual-energy x-ray absorptiometry (DXA) T score is between −1.5 and −2.5, Dr. David L. Kendler, president of the International Society for Clinical Densitometry, explained at the annual meeting of the American Association of Clinical Endocrinologists.

Evidence shows that half or more of low-impact fractures actually occur in this group, he said. In the current NOF guide, treatment is recommended for all postmenopausal women with prior fracture; for postmenopausal women with a T score below −2 and no risk factors; and for postmenopausal women with a T score below −1.5 if they have at least one risk factor.

By comparison, “the [draft] WHO algorithm accounts for the impact of risk factors and for the interactions among risk factors. This is a sophisticated and advanced use of risk factor information,” Dr. Dawson-Hughes said, adding that an advantage of the upcoming NOF guide is that it will better utilize the individual's risk profile to predict fracture.

The new algorithm is based on data from 60,000 subjects. It will enable a physician to estimate a woman's 10-year risk of fracture on the basis of her femoral-neck T score and/or body mass index, together with a number of risk factors. So far, a 12% 10-year risk warrants treatment, although the exact percentage risk that will be used will probably vary by country, Dr. Kendler said.

Corticosteroid use and other secondary causes of osteoporosis are included in the new NOF guide; they are not in the current one, which was issued in 1999. The risk factors are also handled differently, explained Dr. Dawson-Hughes, who is the immediate past president of the NOF.

A case in point: A 60-year-old woman who went through menopause at age 52 and who was not on hormone therapy would have a femoral-neck T score of −1.6.

According to most current osteoporosis guidelines, treatment would not be advised. However, according to the draft WHO algorithm, because she is a smoker and her mother had a hip fracture, her 10-year risk of fracture is actually 15%, and therefore treatment would be warranted, Dr. Kendler said.

The algorithm, which is being developed by Dr. John Kanis of the WHO Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield (England), is expected to be finalized and released this year, Dr. Kendler added.

'We are under increasing pressure to develop' ways to identify patients who will benefit from treatment. DR. DAWSON-HUGHES

Timothy F. Kirn of the Sacramento Bureau contributed to this report.

Updated guidelines slated for release this year should make it easier for physicians and patients to manage osteoporosis and make informed treatment decisions, according to Dr. Bess Dawson-Hughes, director of the bone metabolism laboratory at Tufts University, Boston.

“We are under increasing pressure to develop ways to better identify those patients who will benefit most from treatment,” Dr. Dawson-Hughes said at the annual meeting of the International Society for Clinical Densitometry in Tampa.

The National Osteoporosis Foundation (NOF) is revising its Physician's Guide to Prevention and Treatment of Osteoporosis to incorporate a new World Health Organization (WHO) algorithm that evaluates absolute fracture risk.

Absolute fracture risk is easier for patients to understand than are T scores or z scores, so the phrase “Know your fracture risk” will replace “Know your T score” as the message for patients. The use of absolute fracture risk should allow patients to consider their osteoporosis risk in the context of other chronic disease risks, and to facilitate better decision making concerning osteoporosis treatment, she said.

The need for the updated algorithm is largely to expand treatment to those women who do not clearly have osteoporosis and for whom there has not been a consensus about when to treat—that is, primarily those postmenopausal women whose dual-energy x-ray absorptiometry (DXA) T score is between −1.5 and −2.5, Dr. David L. Kendler, president of the International Society for Clinical Densitometry, explained at the annual meeting of the American Association of Clinical Endocrinologists.

Evidence shows that half or more of low-impact fractures actually occur in this group, he said. In the current NOF guide, treatment is recommended for all postmenopausal women with prior fracture; for postmenopausal women with a T score below −2 and no risk factors; and for postmenopausal women with a T score below −1.5 if they have at least one risk factor.

By comparison, “the [draft] WHO algorithm accounts for the impact of risk factors and for the interactions among risk factors. This is a sophisticated and advanced use of risk factor information,” Dr. Dawson-Hughes said, adding that an advantage of the upcoming NOF guide is that it will better utilize the individual's risk profile to predict fracture.

The new algorithm is based on data from 60,000 subjects. It will enable a physician to estimate a woman's 10-year risk of fracture on the basis of her femoral-neck T score and/or body mass index, together with a number of risk factors. So far, a 12% 10-year risk warrants treatment, although the exact percentage risk that will be used will probably vary by country, Dr. Kendler said.

Corticosteroid use and other secondary causes of osteoporosis are included in the new NOF guide; they are not in the current one, which was issued in 1999. The risk factors are also handled differently, explained Dr. Dawson-Hughes, who is the immediate past president of the NOF.

A case in point: A 60-year-old woman who went through menopause at age 52 and who was not on hormone therapy would have a femoral-neck T score of −1.6.

According to most current osteoporosis guidelines, treatment would not be advised. However, according to the draft WHO algorithm, because she is a smoker and her mother had a hip fracture, her 10-year risk of fracture is actually 15%, and therefore treatment would be warranted, Dr. Kendler said.

The algorithm, which is being developed by Dr. John Kanis of the WHO Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield (England), is expected to be finalized and released this year, Dr. Kendler added.

'We are under increasing pressure to develop' ways to identify patients who will benefit from treatment. DR. DAWSON-HUGHES

Timothy F. Kirn of the Sacramento Bureau contributed to this report.

Updated guidelines slated for release this year should make it easier for physicians and patients to manage osteoporosis and make informed treatment decisions, according to Dr. Bess Dawson-Hughes, director of the bone metabolism laboratory at Tufts University, Boston.

“We are under increasing pressure to develop ways to better identify those patients who will benefit most from treatment,” Dr. Dawson-Hughes said at the annual meeting of the International Society for Clinical Densitometry in Tampa.

The National Osteoporosis Foundation (NOF) is revising its Physician's Guide to Prevention and Treatment of Osteoporosis to incorporate a new World Health Organization (WHO) algorithm that evaluates absolute fracture risk.

Absolute fracture risk is easier for patients to understand than are T scores or z scores, so the phrase “Know your fracture risk” will replace “Know your T score” as the message for patients. The use of absolute fracture risk should allow patients to consider their osteoporosis risk in the context of other chronic disease risks, and to facilitate better decision making concerning osteoporosis treatment, she said.

The need for the updated algorithm is largely to expand treatment to those women who do not clearly have osteoporosis and for whom there has not been a consensus about when to treat—that is, primarily those postmenopausal women whose dual-energy x-ray absorptiometry (DXA) T score is between −1.5 and −2.5, Dr. David L. Kendler, president of the International Society for Clinical Densitometry, explained at the annual meeting of the American Association of Clinical Endocrinologists.

Evidence shows that half or more of low-impact fractures actually occur in this group, he said. In the current NOF guide, treatment is recommended for all postmenopausal women with prior fracture; for postmenopausal women with a T score below −2 and no risk factors; and for postmenopausal women with a T score below −1.5 if they have at least one risk factor.

By comparison, “the [draft] WHO algorithm accounts for the impact of risk factors and for the interactions among risk factors. This is a sophisticated and advanced use of risk factor information,” Dr. Dawson-Hughes said, adding that an advantage of the upcoming NOF guide is that it will better utilize the individual's risk profile to predict fracture.

The new algorithm is based on data from 60,000 subjects. It will enable a physician to estimate a woman's 10-year risk of fracture on the basis of her femoral-neck T score and/or body mass index, together with a number of risk factors. So far, a 12% 10-year risk warrants treatment, although the exact percentage risk that will be used will probably vary by country, Dr. Kendler said.

Corticosteroid use and other secondary causes of osteoporosis are included in the new NOF guide; they are not in the current one, which was issued in 1999. The risk factors are also handled differently, explained Dr. Dawson-Hughes, who is the immediate past president of the NOF.

A case in point: A 60-year-old woman who went through menopause at age 52 and who was not on hormone therapy would have a femoral-neck T score of −1.6.

According to most current osteoporosis guidelines, treatment would not be advised. However, according to the draft WHO algorithm, because she is a smoker and her mother had a hip fracture, her 10-year risk of fracture is actually 15%, and therefore treatment would be warranted, Dr. Kendler said.

The algorithm, which is being developed by Dr. John Kanis of the WHO Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield (England), is expected to be finalized and released this year, Dr. Kendler added.

'We are under increasing pressure to develop' ways to identify patients who will benefit from treatment. DR. DAWSON-HUGHES

BMD 'is lower when anorexia nervosa begins in adolescence than when it occurs in adult life.' DR. CRAWFORD

TAMPA — Anorexia nervosa reduces bone mass and puts young women at risk for early onset of osteoporosis, just at the time when they should be building peak bone mass, Dr. Steven Crawford said at the annual meeting of the International Society for Clinical Densitometry.

Health consequences of anorexia nervosa can be severe. In addition to loss of bone density, the patient can suffer cardiovascular problems, muscle loss and weakness, severe dehydration, anemia, and leukopenia. Female patients with anorexia nervosa are amenorrheic. Anorexia nervosa leads to a sevenfold increase in fracture risk. Of adult women with anorexia nervosa, 38% have osteoporosis, and 50% have a bone mineral density (BMD) level below the fracture threshold.

The extent of bone damage is directly affected by the severity of malnutrition and the disease duration. Consequences are more severe when disease onset occurs during the time of peak bone development. Approximately 60% of total bone mass is attained in the growth spurt that normally occurs in adolescence, and skeletal growth essentially is complete by age 18.

“Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life, even when the duration of illness is comparable,” said Dr. Crawford, a clinical psychiatrist at the Center for Eating Disorders, Sheppard Pratt Health System, Baltimore.

Pathophysiology of low bone density in anorexia nervosa results from multiple factors, including undernutrition, hypogonadism, altered levels of bone-essential hormones and growth factors, excessive exercise, and hypercortisolism, among others. Undernutrition in anorexia nervosa leads to decreased levels of the sex hormones critical for bone development.

Levels of insulinlike growth factor-I (IGF-I) and growth hormone normally increase during puberty, and stimulate bone anabolism. In anorexic patients, IGF-I levels decrease, and patients acquire growth hormone resistance. Lack of calcium may prevent bone remodeling normally stimulated by exercise, and hypogonadism may impair the function of osteocytes that normally are activated by exercise.

Low BMD occurs at all skeletal sites in patients with anorexia nervosa, affecting both trabecular and cortical bone.

In addition to decreased BMD, another factor that contributes to bone fragility in patients with anorexia nervosa is decreased bone size. Patients with anorexia nervosa develop smaller bones in the vertebral body and femoral neck, compared with normal patients.

Dr. Crawford recommends a routine bone density scan in all patients with anorexia nervosa at disease onset and at least every 2 years thereafter. Restoration of normal weight can improve BMD in anorexic patients, but bone loss may continue, with bone restoration taking at least 21 months. “One-third of women recovering weight continue to have BMD z scores more than two standard deviations below the mean,” said Dr. Crawford. Bisphosphonates are not approved for treatment of premenopausal women. Although adequate calcium and vitamin D intake should be provided to patients with anorexia nervosa, supplementation with calcium and vitamin does not increase BMD in anorexic patients. Some evidence suggests that a combination of twice-daily IGF-I administration and estrogen-progesterone treatment may be effective in increasing BMD in anorexic women. Androgen replacement studies have shown conflicting results.

Normally, patients with osteoporosis are advised to engage in weight-bearing exercise such as walking, stair climbing, and weight lifting. However, for patients with anorexia nervosa, the potential benefits of exercise might be offset by the risk of fractures, delayed weight gain, and exercise-induced amenorrhea. “In our program, we recommend 6 months of abstinence from exercise. Then we reintroduce activity into their lifestyle,” he said.

BMD 'is lower when anorexia nervosa begins in adolescence than when it occurs in adult life.' DR. CRAWFORD

TAMPA — Anorexia nervosa reduces bone mass and puts young women at risk for early onset of osteoporosis, just at the time when they should be building peak bone mass, Dr. Steven Crawford said at the annual meeting of the International Society for Clinical Densitometry.

Health consequences of anorexia nervosa can be severe. In addition to loss of bone density, the patient can suffer cardiovascular problems, muscle loss and weakness, severe dehydration, anemia, and leukopenia. Female patients with anorexia nervosa are amenorrheic. Anorexia nervosa leads to a sevenfold increase in fracture risk. Of adult women with anorexia nervosa, 38% have osteoporosis, and 50% have a bone mineral density (BMD) level below the fracture threshold.

The extent of bone damage is directly affected by the severity of malnutrition and the disease duration. Consequences are more severe when disease onset occurs during the time of peak bone development. Approximately 60% of total bone mass is attained in the growth spurt that normally occurs in adolescence, and skeletal growth essentially is complete by age 18.

“Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life, even when the duration of illness is comparable,” said Dr. Crawford, a clinical psychiatrist at the Center for Eating Disorders, Sheppard Pratt Health System, Baltimore.

Pathophysiology of low bone density in anorexia nervosa results from multiple factors, including undernutrition, hypogonadism, altered levels of bone-essential hormones and growth factors, excessive exercise, and hypercortisolism, among others. Undernutrition in anorexia nervosa leads to decreased levels of the sex hormones critical for bone development.

Levels of insulinlike growth factor-I (IGF-I) and growth hormone normally increase during puberty, and stimulate bone anabolism. In anorexic patients, IGF-I levels decrease, and patients acquire growth hormone resistance. Lack of calcium may prevent bone remodeling normally stimulated by exercise, and hypogonadism may impair the function of osteocytes that normally are activated by exercise.

Low BMD occurs at all skeletal sites in patients with anorexia nervosa, affecting both trabecular and cortical bone.

In addition to decreased BMD, another factor that contributes to bone fragility in patients with anorexia nervosa is decreased bone size. Patients with anorexia nervosa develop smaller bones in the vertebral body and femoral neck, compared with normal patients.

Dr. Crawford recommends a routine bone density scan in all patients with anorexia nervosa at disease onset and at least every 2 years thereafter. Restoration of normal weight can improve BMD in anorexic patients, but bone loss may continue, with bone restoration taking at least 21 months. “One-third of women recovering weight continue to have BMD z scores more than two standard deviations below the mean,” said Dr. Crawford. Bisphosphonates are not approved for treatment of premenopausal women. Although adequate calcium and vitamin D intake should be provided to patients with anorexia nervosa, supplementation with calcium and vitamin does not increase BMD in anorexic patients. Some evidence suggests that a combination of twice-daily IGF-I administration and estrogen-progesterone treatment may be effective in increasing BMD in anorexic women. Androgen replacement studies have shown conflicting results.

Normally, patients with osteoporosis are advised to engage in weight-bearing exercise such as walking, stair climbing, and weight lifting. However, for patients with anorexia nervosa, the potential benefits of exercise might be offset by the risk of fractures, delayed weight gain, and exercise-induced amenorrhea. “In our program, we recommend 6 months of abstinence from exercise. Then we reintroduce activity into their lifestyle,” he said.

BMD 'is lower when anorexia nervosa begins in adolescence than when it occurs in adult life.' DR. CRAWFORD

TAMPA — Anorexia nervosa reduces bone mass and puts young women at risk for early onset of osteoporosis, just at the time when they should be building peak bone mass, Dr. Steven Crawford said at the annual meeting of the International Society for Clinical Densitometry.

Health consequences of anorexia nervosa can be severe. In addition to loss of bone density, the patient can suffer cardiovascular problems, muscle loss and weakness, severe dehydration, anemia, and leukopenia. Female patients with anorexia nervosa are amenorrheic. Anorexia nervosa leads to a sevenfold increase in fracture risk. Of adult women with anorexia nervosa, 38% have osteoporosis, and 50% have a bone mineral density (BMD) level below the fracture threshold.

The extent of bone damage is directly affected by the severity of malnutrition and the disease duration. Consequences are more severe when disease onset occurs during the time of peak bone development. Approximately 60% of total bone mass is attained in the growth spurt that normally occurs in adolescence, and skeletal growth essentially is complete by age 18.

“Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life, even when the duration of illness is comparable,” said Dr. Crawford, a clinical psychiatrist at the Center for Eating Disorders, Sheppard Pratt Health System, Baltimore.

Pathophysiology of low bone density in anorexia nervosa results from multiple factors, including undernutrition, hypogonadism, altered levels of bone-essential hormones and growth factors, excessive exercise, and hypercortisolism, among others. Undernutrition in anorexia nervosa leads to decreased levels of the sex hormones critical for bone development.

Levels of insulinlike growth factor-I (IGF-I) and growth hormone normally increase during puberty, and stimulate bone anabolism. In anorexic patients, IGF-I levels decrease, and patients acquire growth hormone resistance. Lack of calcium may prevent bone remodeling normally stimulated by exercise, and hypogonadism may impair the function of osteocytes that normally are activated by exercise.

Low BMD occurs at all skeletal sites in patients with anorexia nervosa, affecting both trabecular and cortical bone.

In addition to decreased BMD, another factor that contributes to bone fragility in patients with anorexia nervosa is decreased bone size. Patients with anorexia nervosa develop smaller bones in the vertebral body and femoral neck, compared with normal patients.

Dr. Crawford recommends a routine bone density scan in all patients with anorexia nervosa at disease onset and at least every 2 years thereafter. Restoration of normal weight can improve BMD in anorexic patients, but bone loss may continue, with bone restoration taking at least 21 months. “One-third of women recovering weight continue to have BMD z scores more than two standard deviations below the mean,” said Dr. Crawford. Bisphosphonates are not approved for treatment of premenopausal women. Although adequate calcium and vitamin D intake should be provided to patients with anorexia nervosa, supplementation with calcium and vitamin does not increase BMD in anorexic patients. Some evidence suggests that a combination of twice-daily IGF-I administration and estrogen-progesterone treatment may be effective in increasing BMD in anorexic women. Androgen replacement studies have shown conflicting results.

Normally, patients with osteoporosis are advised to engage in weight-bearing exercise such as walking, stair climbing, and weight lifting. However, for patients with anorexia nervosa, the potential benefits of exercise might be offset by the risk of fractures, delayed weight gain, and exercise-induced amenorrhea. “In our program, we recommend 6 months of abstinence from exercise. Then we reintroduce activity into their lifestyle,” he said.

TAMPA — Spinal osteoarthritis can occur following osteoporotic end-plate perforation and can lead to a falsely high bone mineral density score, Dr. Sumiaki Okamoto of the Okamoto Clinic in Oita, Japan, and colleagues reported in a poster presentation at the annual meeting of the International Society of Clinical Densitometry.

Dr. Okamoto and colleagues analyzed the relationship between lumbar bone mineral density (BMD) scores and the presence of multiple perforations in vertebral end plates in postmenopausal women with osteoporosis and related secondary osteoarthritis (OA).

The study population consisted of postmenopausal women aged 45–85 as well as healthy premenopausal women who were aged 20–40. The majority of the postmenopausal women studied had both osteoporosis as well as spinal osteoarthritis.

At a single outpatient clinic in Oita, Japan, investigators performed 3-D helical CT scans on 1,240 spines.

Perforations were frequently seen in vertebral end plates in untreated postmenopausal female patients but rarely were observed in premenopausal women volunteers.

The perforations were first seen soon after menopause and increased in number over time. The ratio of perforations to vertebral end-plate area was significantly correlated with the number of years after menopause.

Dr. Okamoto and colleagues speculate that perforations might originate from the circulatory system, as blood vessels pierce the vertebral end plate to nourish the intervertebral disks.

If a disk is herniated and under pressure, the disk nucleus could escape though the perforations. This occurrence could account for the loss of the watery content of disk cartilage that is associated with osteoarthritis.

“Overadaptation” of bone after osteoporosis leads to formation of multiple Schmorl's nodes at fracture lines. Serial radiographs documented the growth of osteophytes after fresh fractures in one patient. In another patient, serial radiographs revealed the disappearance of prominent osteophytes after stabilization.

Fracture lines did not appear to be smooth in the 3-D images. Instead, the images showed mixtures of perforated indentations or Schmorl's nodes, which indicated expansion of the disk space together with convergence of the rims of the vertebrae.

“The finding suggests that disk herniation into the weakened vertebral body through the perforated end plates can cause osteoarthritis in the same manner as the lateral slippage of the disk,” wrote the investigators.

“What has conventionally been known as fish-shaped vertebral fractures may in fact be secondary to the herniation of the disk nucleus into the weakened vertebral body of the osteoporotic spine,” the researchers added.

In this situation, the osteoarthritic changes are due to the bone, rather than the cartilage, and result from overadaptation. The intervertebral space narrows and the osteophytes surrounding the vertebral end plates fuse.

“The unloaded vertebral end plates disappear rapidly when the surrounding osteophytes fuse together like a single pipe to support the load,” wrote the study investigators. Furthermore, sclerotic calcification or callus formation around the end-plate perforations adds to an erroneously high lumbar BMD score. “I find it intriguing to connect two common illnesses, such as spinal osteoporosis and fractures, with vertebral osteoarthritis,” Dr. Harold Rosen of Beth Israel Deaconess Medical Center in Boston said in an interview.

“However, further research needs to be done to support this assertion, such as finding that the BMD at sites other than the spine is low in patients with spine OA,” Dr. Rosen added.

TAMPA — Spinal osteoarthritis can occur following osteoporotic end-plate perforation and can lead to a falsely high bone mineral density score, Dr. Sumiaki Okamoto of the Okamoto Clinic in Oita, Japan, and colleagues reported in a poster presentation at the annual meeting of the International Society of Clinical Densitometry.

Dr. Okamoto and colleagues analyzed the relationship between lumbar bone mineral density (BMD) scores and the presence of multiple perforations in vertebral end plates in postmenopausal women with osteoporosis and related secondary osteoarthritis (OA).

The study population consisted of postmenopausal women aged 45–85 as well as healthy premenopausal women who were aged 20–40. The majority of the postmenopausal women studied had both osteoporosis as well as spinal osteoarthritis.

At a single outpatient clinic in Oita, Japan, investigators performed 3-D helical CT scans on 1,240 spines.

Perforations were frequently seen in vertebral end plates in untreated postmenopausal female patients but rarely were observed in premenopausal women volunteers.

The perforations were first seen soon after menopause and increased in number over time. The ratio of perforations to vertebral end-plate area was significantly correlated with the number of years after menopause.

Dr. Okamoto and colleagues speculate that perforations might originate from the circulatory system, as blood vessels pierce the vertebral end plate to nourish the intervertebral disks.

If a disk is herniated and under pressure, the disk nucleus could escape though the perforations. This occurrence could account for the loss of the watery content of disk cartilage that is associated with osteoarthritis.

“Overadaptation” of bone after osteoporosis leads to formation of multiple Schmorl's nodes at fracture lines. Serial radiographs documented the growth of osteophytes after fresh fractures in one patient. In another patient, serial radiographs revealed the disappearance of prominent osteophytes after stabilization.

Fracture lines did not appear to be smooth in the 3-D images. Instead, the images showed mixtures of perforated indentations or Schmorl's nodes, which indicated expansion of the disk space together with convergence of the rims of the vertebrae.

“The finding suggests that disk herniation into the weakened vertebral body through the perforated end plates can cause osteoarthritis in the same manner as the lateral slippage of the disk,” wrote the investigators.

“What has conventionally been known as fish-shaped vertebral fractures may in fact be secondary to the herniation of the disk nucleus into the weakened vertebral body of the osteoporotic spine,” the researchers added.

In this situation, the osteoarthritic changes are due to the bone, rather than the cartilage, and result from overadaptation. The intervertebral space narrows and the osteophytes surrounding the vertebral end plates fuse.

“The unloaded vertebral end plates disappear rapidly when the surrounding osteophytes fuse together like a single pipe to support the load,” wrote the study investigators. Furthermore, sclerotic calcification or callus formation around the end-plate perforations adds to an erroneously high lumbar BMD score. “I find it intriguing to connect two common illnesses, such as spinal osteoporosis and fractures, with vertebral osteoarthritis,” Dr. Harold Rosen of Beth Israel Deaconess Medical Center in Boston said in an interview.

“However, further research needs to be done to support this assertion, such as finding that the BMD at sites other than the spine is low in patients with spine OA,” Dr. Rosen added.

TAMPA — Spinal osteoarthritis can occur following osteoporotic end-plate perforation and can lead to a falsely high bone mineral density score, Dr. Sumiaki Okamoto of the Okamoto Clinic in Oita, Japan, and colleagues reported in a poster presentation at the annual meeting of the International Society of Clinical Densitometry.

Dr. Okamoto and colleagues analyzed the relationship between lumbar bone mineral density (BMD) scores and the presence of multiple perforations in vertebral end plates in postmenopausal women with osteoporosis and related secondary osteoarthritis (OA).

The study population consisted of postmenopausal women aged 45–85 as well as healthy premenopausal women who were aged 20–40. The majority of the postmenopausal women studied had both osteoporosis as well as spinal osteoarthritis.

At a single outpatient clinic in Oita, Japan, investigators performed 3-D helical CT scans on 1,240 spines.

Perforations were frequently seen in vertebral end plates in untreated postmenopausal female patients but rarely were observed in premenopausal women volunteers.

The perforations were first seen soon after menopause and increased in number over time. The ratio of perforations to vertebral end-plate area was significantly correlated with the number of years after menopause.

Dr. Okamoto and colleagues speculate that perforations might originate from the circulatory system, as blood vessels pierce the vertebral end plate to nourish the intervertebral disks.

If a disk is herniated and under pressure, the disk nucleus could escape though the perforations. This occurrence could account for the loss of the watery content of disk cartilage that is associated with osteoarthritis.

“Overadaptation” of bone after osteoporosis leads to formation of multiple Schmorl's nodes at fracture lines. Serial radiographs documented the growth of osteophytes after fresh fractures in one patient. In another patient, serial radiographs revealed the disappearance of prominent osteophytes after stabilization.

Fracture lines did not appear to be smooth in the 3-D images. Instead, the images showed mixtures of perforated indentations or Schmorl's nodes, which indicated expansion of the disk space together with convergence of the rims of the vertebrae.

“The finding suggests that disk herniation into the weakened vertebral body through the perforated end plates can cause osteoarthritis in the same manner as the lateral slippage of the disk,” wrote the investigators.

“What has conventionally been known as fish-shaped vertebral fractures may in fact be secondary to the herniation of the disk nucleus into the weakened vertebral body of the osteoporotic spine,” the researchers added.

In this situation, the osteoarthritic changes are due to the bone, rather than the cartilage, and result from overadaptation. The intervertebral space narrows and the osteophytes surrounding the vertebral end plates fuse.

“The unloaded vertebral end plates disappear rapidly when the surrounding osteophytes fuse together like a single pipe to support the load,” wrote the study investigators. Furthermore, sclerotic calcification or callus formation around the end-plate perforations adds to an erroneously high lumbar BMD score. “I find it intriguing to connect two common illnesses, such as spinal osteoporosis and fractures, with vertebral osteoarthritis,” Dr. Harold Rosen of Beth Israel Deaconess Medical Center in Boston said in an interview.

“However, further research needs to be done to support this assertion, such as finding that the BMD at sites other than the spine is low in patients with spine OA,” Dr. Rosen added.

TAMPA — Dual-energy x-ray absorptiometry is an excellent method to measure and monitor body composition changes in obese patients undergoing weight loss and to assess body composition in athletes, Dr. Mary K. Oates reported at the annual meeting of the International Society for Clinical Densitometry.

Although this application is not reimbursable by medical insurance, many patients concerned about fitness and weight loss are willing to pay out of pocket to have a direct measurement of their percent lean mass and percent fat, said Dr. Oates, who is board certified in physical medicine and rehabilitation and has private clinics in Santa Maria and Pismo Beach, Calif.

Unlike other methods for assessing body composition, dual-energy x-ray absorptiometry (DXA) “can give you regional values, not just total body fat,” she said. “Olympic athletes and professional athletes want to know, How much muscle do I have in my leg? How much muscle did my injured quarterback lose in his throwing arm after his injury?” DXA also provides a dramatic total body image of the skeleton and soft tissue.

DXA is being used by the Green Bay Packers pro football team and at the U.S. Olympic Training Center in Colorado Springs to provide benchmarks for performance enhancement, she said.

Most methods that have been widely used to estimate body composition are indirect. Epidemiology studies usually rely on measurement of waist and hip circumferences and calculation of waist:hip ratio, as well as body mass index. Determination of BMI is often used to define obesity, although BMI does not account for percent body fat. A nonobese, muscular individual may have a BMI score in the obese range.

Digital scales use bioelectrical impedance analysis to estimate percent body fat. Another indirect method that is widely used in health clubs is skin-fold measurement, in which calipers measure the skin at the back of the upper arms or the stomach ("pinch test").

Calculation of total body fat is based on the assumption that the amount of subcutaneous fat is proportional to the total body fat.

“It is assumed that about one-third of the total fat is located subcutaneously, but we all know that it varies with sex, age, ethnicity, and individual fat distribution,” Dr. Oates said.

The “dunk tank” has traditionally been considered the most accurate way to determine body composition, although it is technically difficult for the subject to perform. The Bod Pod is similar to the “dunk tank” but is based on air displacement, rather than water displacement.

In contrast, DXA directly measures fat mass, lean mass, and bone mineral content, and calculates the percentages of fat mass and lean mass. One limitation of DXA is the inability to measure the fat or lean composition of pixels that contain bone, although composition can be estimated from the adjacent pixels.

Different DXA machines have various limits on patient thickness and weight, and most models can't accommodate obese patients who weigh 300 pounds or more, so it's necessary to do a right-sided scan, then double the results to get whole-body estimates, Dr. Oates said. The new Lunar iDXA by GE has a larger table size and weight capacity that allows direct full-body measurement of patients up to 450 pounds and up to 6 feet 5 inches in height.

Individuals who have undergone body fat assessment by another method may be reluctant to accept the DXA results: The percentage of fat may generally be a little higher with DXA than with other methods. “I think that's because we are really measuring three compartments—we are measuring fat, we are measuring muscle, we are measuring bone,” said Dr. Oates, a medical consultant to GE Healthcare Lunar. “The other methods are just estimating from body density.”

To demonstrate the usefulness of DXA in monitoring body composition changes, Dr. Oates offered to work with the producers of “The Biggest Loser,” an NBC television reality show in which morbidly obese contestants compete to lose weight through aggressive diet and exercise. DXA provided a graphic visual image of the weight loss and changes in percent body fat of the contestants.

DXA scans can be a powerful motivational tool for patients in weight-loss programs. One advantage of DXA in monitoring weight loss is illustrated by the case of a contestant whose apparent fat loss was greater than the 30-pound weight loss indicated by the scales.

DXA results showed that he had gained 16.5 pounds of muscle. “Muscle weighs more than fat,” Dr. Oates said. “We now can see the breakdown of total weight loss.” The contestant eventually went from 39% body fat to 5.8% body fat.

DXA scans show a 105-kg woman with 53% total body fat before aggressive diet and exercise program (left) and after the program at 57 kg, with 18% total body fat (right). Photos courtesy Dr. Robert Huizenga/Dr. Mary K. Oates

TAMPA — Dual-energy x-ray absorptiometry is an excellent method to measure and monitor body composition changes in obese patients undergoing weight loss and to assess body composition in athletes, Dr. Mary K. Oates reported at the annual meeting of the International Society for Clinical Densitometry.

Although this application is not reimbursable by medical insurance, many patients concerned about fitness and weight loss are willing to pay out of pocket to have a direct measurement of their percent lean mass and percent fat, said Dr. Oates, who is board certified in physical medicine and rehabilitation and has private clinics in Santa Maria and Pismo Beach, Calif.

Unlike other methods for assessing body composition, dual-energy x-ray absorptiometry (DXA) “can give you regional values, not just total body fat,” she said. “Olympic athletes and professional athletes want to know, How much muscle do I have in my leg? How much muscle did my injured quarterback lose in his throwing arm after his injury?” DXA also provides a dramatic total body image of the skeleton and soft tissue.

DXA is being used by the Green Bay Packers pro football team and at the U.S. Olympic Training Center in Colorado Springs to provide benchmarks for performance enhancement, she said.

Most methods that have been widely used to estimate body composition are indirect. Epidemiology studies usually rely on measurement of waist and hip circumferences and calculation of waist:hip ratio, as well as body mass index. Determination of BMI is often used to define obesity, although BMI does not account for percent body fat. A nonobese, muscular individual may have a BMI score in the obese range.

Digital scales use bioelectrical impedance analysis to estimate percent body fat. Another indirect method that is widely used in health clubs is skin-fold measurement, in which calipers measure the skin at the back of the upper arms or the stomach ("pinch test").

Calculation of total body fat is based on the assumption that the amount of subcutaneous fat is proportional to the total body fat.

“It is assumed that about one-third of the total fat is located subcutaneously, but we all know that it varies with sex, age, ethnicity, and individual fat distribution,” Dr. Oates said.

The “dunk tank” has traditionally been considered the most accurate way to determine body composition, although it is technically difficult for the subject to perform. The Bod Pod is similar to the “dunk tank” but is based on air displacement, rather than water displacement.

In contrast, DXA directly measures fat mass, lean mass, and bone mineral content, and calculates the percentages of fat mass and lean mass. One limitation of DXA is the inability to measure the fat or lean composition of pixels that contain bone, although composition can be estimated from the adjacent pixels.

Different DXA machines have various limits on patient thickness and weight, and most models can't accommodate obese patients who weigh 300 pounds or more, so it's necessary to do a right-sided scan, then double the results to get whole-body estimates, Dr. Oates said. The new Lunar iDXA by GE has a larger table size and weight capacity that allows direct full-body measurement of patients up to 450 pounds and up to 6 feet 5 inches in height.

Individuals who have undergone body fat assessment by another method may be reluctant to accept the DXA results: The percentage of fat may generally be a little higher with DXA than with other methods. “I think that's because we are really measuring three compartments—we are measuring fat, we are measuring muscle, we are measuring bone,” said Dr. Oates, a medical consultant to GE Healthcare Lunar. “The other methods are just estimating from body density.”

To demonstrate the usefulness of DXA in monitoring body composition changes, Dr. Oates offered to work with the producers of “The Biggest Loser,” an NBC television reality show in which morbidly obese contestants compete to lose weight through aggressive diet and exercise. DXA provided a graphic visual image of the weight loss and changes in percent body fat of the contestants.

DXA scans can be a powerful motivational tool for patients in weight-loss programs. One advantage of DXA in monitoring weight loss is illustrated by the case of a contestant whose apparent fat loss was greater than the 30-pound weight loss indicated by the scales.

DXA results showed that he had gained 16.5 pounds of muscle. “Muscle weighs more than fat,” Dr. Oates said. “We now can see the breakdown of total weight loss.” The contestant eventually went from 39% body fat to 5.8% body fat.

DXA scans show a 105-kg woman with 53% total body fat before aggressive diet and exercise program (left) and after the program at 57 kg, with 18% total body fat (right). Photos courtesy Dr. Robert Huizenga/Dr. Mary K. Oates

TAMPA — Dual-energy x-ray absorptiometry is an excellent method to measure and monitor body composition changes in obese patients undergoing weight loss and to assess body composition in athletes, Dr. Mary K. Oates reported at the annual meeting of the International Society for Clinical Densitometry.

Although this application is not reimbursable by medical insurance, many patients concerned about fitness and weight loss are willing to pay out of pocket to have a direct measurement of their percent lean mass and percent fat, said Dr. Oates, who is board certified in physical medicine and rehabilitation and has private clinics in Santa Maria and Pismo Beach, Calif.

Unlike other methods for assessing body composition, dual-energy x-ray absorptiometry (DXA) “can give you regional values, not just total body fat,” she said. “Olympic athletes and professional athletes want to know, How much muscle do I have in my leg? How much muscle did my injured quarterback lose in his throwing arm after his injury?” DXA also provides a dramatic total body image of the skeleton and soft tissue.

DXA is being used by the Green Bay Packers pro football team and at the U.S. Olympic Training Center in Colorado Springs to provide benchmarks for performance enhancement, she said.

Most methods that have been widely used to estimate body composition are indirect. Epidemiology studies usually rely on measurement of waist and hip circumferences and calculation of waist:hip ratio, as well as body mass index. Determination of BMI is often used to define obesity, although BMI does not account for percent body fat. A nonobese, muscular individual may have a BMI score in the obese range.

Digital scales use bioelectrical impedance analysis to estimate percent body fat. Another indirect method that is widely used in health clubs is skin-fold measurement, in which calipers measure the skin at the back of the upper arms or the stomach ("pinch test").

Calculation of total body fat is based on the assumption that the amount of subcutaneous fat is proportional to the total body fat.

“It is assumed that about one-third of the total fat is located subcutaneously, but we all know that it varies with sex, age, ethnicity, and individual fat distribution,” Dr. Oates said.

The “dunk tank” has traditionally been considered the most accurate way to determine body composition, although it is technically difficult for the subject to perform. The Bod Pod is similar to the “dunk tank” but is based on air displacement, rather than water displacement.

In contrast, DXA directly measures fat mass, lean mass, and bone mineral content, and calculates the percentages of fat mass and lean mass. One limitation of DXA is the inability to measure the fat or lean composition of pixels that contain bone, although composition can be estimated from the adjacent pixels.

Different DXA machines have various limits on patient thickness and weight, and most models can't accommodate obese patients who weigh 300 pounds or more, so it's necessary to do a right-sided scan, then double the results to get whole-body estimates, Dr. Oates said. The new Lunar iDXA by GE has a larger table size and weight capacity that allows direct full-body measurement of patients up to 450 pounds and up to 6 feet 5 inches in height.

Individuals who have undergone body fat assessment by another method may be reluctant to accept the DXA results: The percentage of fat may generally be a little higher with DXA than with other methods. “I think that's because we are really measuring three compartments—we are measuring fat, we are measuring muscle, we are measuring bone,” said Dr. Oates, a medical consultant to GE Healthcare Lunar. “The other methods are just estimating from body density.”

To demonstrate the usefulness of DXA in monitoring body composition changes, Dr. Oates offered to work with the producers of “The Biggest Loser,” an NBC television reality show in which morbidly obese contestants compete to lose weight through aggressive diet and exercise. DXA provided a graphic visual image of the weight loss and changes in percent body fat of the contestants.

DXA scans can be a powerful motivational tool for patients in weight-loss programs. One advantage of DXA in monitoring weight loss is illustrated by the case of a contestant whose apparent fat loss was greater than the 30-pound weight loss indicated by the scales.

DXA results showed that he had gained 16.5 pounds of muscle. “Muscle weighs more than fat,” Dr. Oates said. “We now can see the breakdown of total weight loss.” The contestant eventually went from 39% body fat to 5.8% body fat.

DXA scans show a 105-kg woman with 53% total body fat before aggressive diet and exercise program (left) and after the program at 57 kg, with 18% total body fat (right). Photos courtesy Dr. Robert Huizenga/Dr. Mary K. Oates

TAMPA, FLA. — Dual-energy x-ray absorptiometry is an excellent method to measure and monitor body composition changes in obese patients undergoing weight loss and to assess body composition in athletes, Dr. Mary K. Oates reported at the annual meeting of the International Society for Clinical Densitometry.

Although this application is not reimbursable by medical insurance, many patients concerned about fitness and weight loss are willing to pay out of pocket to have a direct measurement of their percent lean mass and percent fat, said Dr. Oates, who is board-certified in physical medicine and rehabilitation and has private clinics in Santa Maria and Pismo Beach, Calif.

Unlike other methods for assessing body composition, dual-energy x-ray absorptiometry (DXA) “can give you regional values, not just total body fat,” she said. “Olympic athletes and professional athletes want to know, How much muscle do I have in my leg? How much muscle did my injured quarterback lose in his throwing arm after his injury?” DXA also provides a dramatic total body image of the skeleton and soft tissue.

DXA is being used by the Green Bay Packers pro football team and at the U.S. Olympic Training Center in Colorado Springs, Colo. to provide benchmarks for performance enhancement, she said.

Most methods that have been widely used to estimate body composition are indirect. Epidemiology studies usually rely on measurement of waist and hip circumferences and calculation of waist:hip ratio, as well as body mass index. Determination of BMI is often used to define obesity, although BMI does not account for percent body fat. A nonobese, muscular individual may have a BMI score in the obese range.

Digital scales use bioelectrical impedance analysis to estimate percent body fat. Another indirect method that is widely used in health clubs is skin-fold measurement, in which calipers measure the skin at the back of the upper arms or the stomach (“pinch test”). Calculation of total body fat is based on the assumption that the amount of subcutaneous fat is proportional to the total body fat. “It is assumed that about one-third of the total fat is located subcutaneously, but we all know that it varies with sex, age, ethnicity, and individual fat distribution,” Dr. Oates said.

The “dunk tank” has traditionally been considered the most accurate way to determine body composition, although it is technically difficult for the subject to perform. The Bod Pod is similar to the “dunk tank” but is based on air displacement, rather than water displacement.

In contrast, DXA directly measures fat mass, lean mass, and bone mineral content, and calculates the percentages of fat mass and lean mass. One limitation of DXA is the inability to measure the fat or lean composition of pixels that contain bone, although composition can be estimated from the adjacent pixels.

Different DXA machines have various limits on patient thickness and weight, and most models can't accommodate obese patients who weigh 300 pounds or more, so it's necessary to do a right-sided scan, then double the results to get whole-body estimates, Dr. Oates said. The new Lunar iDXA by GE has a larger table size and weight capacity that allows direct full-body measurement of patients up to 450 pounds and 6'5”.

Individuals who have undergone body fat assessment by another method may be reluctant to accept the DXA results: The percent fat may generally be a little higher with DXA than with other methods. “I think that's because we are really measuring three compartments—we are measuring fat, we are measuring muscle, we are measuring bone,” said Dr. Oates, a medical consultant to GE Healthcare Lunar. “The other methods are just estimating from body density.”

Unlike dunk tanks, DXA directly measures fat mass, lean mass, and bone mineral content. This 105-kg white female was shown to have 53% total body fat before undergoing an aggressive diet and exercise program. Courtesy Dr. Robert Huizenga/Dr. Mary K. Oates

TAMPA, FLA. — Dual-energy x-ray absorptiometry is an excellent method to measure and monitor body composition changes in obese patients undergoing weight loss and to assess body composition in athletes, Dr. Mary K. Oates reported at the annual meeting of the International Society for Clinical Densitometry.

Although this application is not reimbursable by medical insurance, many patients concerned about fitness and weight loss are willing to pay out of pocket to have a direct measurement of their percent lean mass and percent fat, said Dr. Oates, who is board-certified in physical medicine and rehabilitation and has private clinics in Santa Maria and Pismo Beach, Calif.

Unlike other methods for assessing body composition, dual-energy x-ray absorptiometry (DXA) “can give you regional values, not just total body fat,” she said. “Olympic athletes and professional athletes want to know, How much muscle do I have in my leg? How much muscle did my injured quarterback lose in his throwing arm after his injury?” DXA also provides a dramatic total body image of the skeleton and soft tissue.

DXA is being used by the Green Bay Packers pro football team and at the U.S. Olympic Training Center in Colorado Springs, Colo. to provide benchmarks for performance enhancement, she said.

Most methods that have been widely used to estimate body composition are indirect. Epidemiology studies usually rely on measurement of waist and hip circumferences and calculation of waist:hip ratio, as well as body mass index. Determination of BMI is often used to define obesity, although BMI does not account for percent body fat. A nonobese, muscular individual may have a BMI score in the obese range.

Digital scales use bioelectrical impedance analysis to estimate percent body fat. Another indirect method that is widely used in health clubs is skin-fold measurement, in which calipers measure the skin at the back of the upper arms or the stomach (“pinch test”). Calculation of total body fat is based on the assumption that the amount of subcutaneous fat is proportional to the total body fat. “It is assumed that about one-third of the total fat is located subcutaneously, but we all know that it varies with sex, age, ethnicity, and individual fat distribution,” Dr. Oates said.

The “dunk tank” has traditionally been considered the most accurate way to determine body composition, although it is technically difficult for the subject to perform. The Bod Pod is similar to the “dunk tank” but is based on air displacement, rather than water displacement.

In contrast, DXA directly measures fat mass, lean mass, and bone mineral content, and calculates the percentages of fat mass and lean mass. One limitation of DXA is the inability to measure the fat or lean composition of pixels that contain bone, although composition can be estimated from the adjacent pixels.

Different DXA machines have various limits on patient thickness and weight, and most models can't accommodate obese patients who weigh 300 pounds or more, so it's necessary to do a right-sided scan, then double the results to get whole-body estimates, Dr. Oates said. The new Lunar iDXA by GE has a larger table size and weight capacity that allows direct full-body measurement of patients up to 450 pounds and 6'5”.

Individuals who have undergone body fat assessment by another method may be reluctant to accept the DXA results: The percent fat may generally be a little higher with DXA than with other methods. “I think that's because we are really measuring three compartments—we are measuring fat, we are measuring muscle, we are measuring bone,” said Dr. Oates, a medical consultant to GE Healthcare Lunar. “The other methods are just estimating from body density.”

Unlike dunk tanks, DXA directly measures fat mass, lean mass, and bone mineral content. This 105-kg white female was shown to have 53% total body fat before undergoing an aggressive diet and exercise program. Courtesy Dr. Robert Huizenga/Dr. Mary K. Oates

TAMPA, FLA. — Dual-energy x-ray absorptiometry is an excellent method to measure and monitor body composition changes in obese patients undergoing weight loss and to assess body composition in athletes, Dr. Mary K. Oates reported at the annual meeting of the International Society for Clinical Densitometry.

Although this application is not reimbursable by medical insurance, many patients concerned about fitness and weight loss are willing to pay out of pocket to have a direct measurement of their percent lean mass and percent fat, said Dr. Oates, who is board-certified in physical medicine and rehabilitation and has private clinics in Santa Maria and Pismo Beach, Calif.

Unlike other methods for assessing body composition, dual-energy x-ray absorptiometry (DXA) “can give you regional values, not just total body fat,” she said. “Olympic athletes and professional athletes want to know, How much muscle do I have in my leg? How much muscle did my injured quarterback lose in his throwing arm after his injury?” DXA also provides a dramatic total body image of the skeleton and soft tissue.

DXA is being used by the Green Bay Packers pro football team and at the U.S. Olympic Training Center in Colorado Springs, Colo. to provide benchmarks for performance enhancement, she said.

Most methods that have been widely used to estimate body composition are indirect. Epidemiology studies usually rely on measurement of waist and hip circumferences and calculation of waist:hip ratio, as well as body mass index. Determination of BMI is often used to define obesity, although BMI does not account for percent body fat. A nonobese, muscular individual may have a BMI score in the obese range.

Digital scales use bioelectrical impedance analysis to estimate percent body fat. Another indirect method that is widely used in health clubs is skin-fold measurement, in which calipers measure the skin at the back of the upper arms or the stomach (“pinch test”). Calculation of total body fat is based on the assumption that the amount of subcutaneous fat is proportional to the total body fat. “It is assumed that about one-third of the total fat is located subcutaneously, but we all know that it varies with sex, age, ethnicity, and individual fat distribution,” Dr. Oates said.

The “dunk tank” has traditionally been considered the most accurate way to determine body composition, although it is technically difficult for the subject to perform. The Bod Pod is similar to the “dunk tank” but is based on air displacement, rather than water displacement.

In contrast, DXA directly measures fat mass, lean mass, and bone mineral content, and calculates the percentages of fat mass and lean mass. One limitation of DXA is the inability to measure the fat or lean composition of pixels that contain bone, although composition can be estimated from the adjacent pixels.

Different DXA machines have various limits on patient thickness and weight, and most models can't accommodate obese patients who weigh 300 pounds or more, so it's necessary to do a right-sided scan, then double the results to get whole-body estimates, Dr. Oates said. The new Lunar iDXA by GE has a larger table size and weight capacity that allows direct full-body measurement of patients up to 450 pounds and 6'5”.

Individuals who have undergone body fat assessment by another method may be reluctant to accept the DXA results: The percent fat may generally be a little higher with DXA than with other methods. “I think that's because we are really measuring three compartments—we are measuring fat, we are measuring muscle, we are measuring bone,” said Dr. Oates, a medical consultant to GE Healthcare Lunar. “The other methods are just estimating from body density.”

Unlike dunk tanks, DXA directly measures fat mass, lean mass, and bone mineral content. This 105-kg white female was shown to have 53% total body fat before undergoing an aggressive diet and exercise program. Courtesy Dr. Robert Huizenga/Dr. Mary K. Oates

TAMPA – Anorexia nervosa reduces bone mass and puts young women at risk for early onset of osteoporosis, just at the time when they should be building peak bone mass, Dr. Steven Crawford said at the annual meeting of the International Society for Clinical Densitometry.

Anorexia nervosa is one of the most common psychiatric diagnoses in adolescent women, with the age of onset showing bimodal peaks at age 14 and 18 years.

Health consequences can be severe. In addition to loss of bone density, patients can suffer cardiovascular problems, muscle loss and weakness, severe dehydration, anemia, and leukopenia. Female patients with anorexia nervosa are amenorrheic. Anorexia nervosa leads to a sevenfold increase in fracture risk. Of adult women with anorexia nervosa, 38% have osteoporosis, and 50% have a bone mineral density (BMD) level below the fracture threshold.

The extent of bone damage is directly affected by the severity of malnutrition and the disease duration. Consequences are more severe when disease onset occurs during the time of peak bone development. Approximately 60% of total bone mass is attained in the growth spurt that normally occurs in adolescence, and skeletal growth essentially is complete by age 18.

“Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life, even when the duration of illness is comparable,” said Dr. Crawford, a clinical psychiatrist at the Center for Eating Disorders, Sheppard Pratt Health System, Baltimore.

Pathophysiology of low bone density in anorexia nervosa results from multiple factors, including undernutrition, hypogonadism, altered levels of bone-essential hormones and growth factors, excessive exercise, and hypercortisolism, among others. Undernutrition in anorexia nervosa leads to decreased levels of the sex hormones critical for bone development.

Low BMD occurs at all skeletal sites in patients with anorexia nervosa, affecting both trabecular and cortical bone. The spine is more likely to be affected than the hip, said Dr. Crawford.

In addition to decreased BMD, another factor that contributes to bone fragility in patients with anorexia nervosa is decreased bone size. Patients with anorexia nervosa develop smaller bones in the vertebral body and femoral neck, compared with normal patients. Consequences of osteoporosis in anorexic patients are stress fractures in weight-bearing bones, and vertebral fractures leading to chronic back pain and reduced height.

Dr. Crawford recommends a routine bone density scan in all patients with anorexia nervosa at disease onset and at least every 2 years thereafter. Restoration of normal weight can improve BMD in anorexic patients, but bone loss may continue, with bone restoration taking at least 21 months. “Overall, data [suggest] despite improvement there are permanent deficits in BMD, underscoring the importance of timely diagnosis and treatment,” she said.

Bisphosphonates are not approved for treatment of premenopausal women. Moreover, the increased bone turnover that occurs normally during adolescence makes the use of bisphosphonates especially controversial for patients in that age group.

Although adequate calcium and vitamin D intake should be provided to patients with anorexia nervosa, supplementation with calcium and vitamin does not increase BMD in anorexic patients. Some evidence suggests that a combination of twice-daily IGF-I administration and estrogen-progesterone treatment may be effective in increasing BMD in anorexic women. Androgen replacement studies have shown conflicting results.

Normally, patients with osteoporosis are advised to engage in weight-bearing exercise such as walking, stair climbing, and weight lifting. However, for patients with anorexia nervosa, the potential benefits of exercise might be offset by the risk of fractures, delayed weight gain, and exercise-induced amenorrhea.

'Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life.' DR. CRAWFORD

TAMPA – Anorexia nervosa reduces bone mass and puts young women at risk for early onset of osteoporosis, just at the time when they should be building peak bone mass, Dr. Steven Crawford said at the annual meeting of the International Society for Clinical Densitometry.

Anorexia nervosa is one of the most common psychiatric diagnoses in adolescent women, with the age of onset showing bimodal peaks at age 14 and 18 years.

Health consequences can be severe. In addition to loss of bone density, patients can suffer cardiovascular problems, muscle loss and weakness, severe dehydration, anemia, and leukopenia. Female patients with anorexia nervosa are amenorrheic. Anorexia nervosa leads to a sevenfold increase in fracture risk. Of adult women with anorexia nervosa, 38% have osteoporosis, and 50% have a bone mineral density (BMD) level below the fracture threshold.

The extent of bone damage is directly affected by the severity of malnutrition and the disease duration. Consequences are more severe when disease onset occurs during the time of peak bone development. Approximately 60% of total bone mass is attained in the growth spurt that normally occurs in adolescence, and skeletal growth essentially is complete by age 18.

“Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life, even when the duration of illness is comparable,” said Dr. Crawford, a clinical psychiatrist at the Center for Eating Disorders, Sheppard Pratt Health System, Baltimore.

Pathophysiology of low bone density in anorexia nervosa results from multiple factors, including undernutrition, hypogonadism, altered levels of bone-essential hormones and growth factors, excessive exercise, and hypercortisolism, among others. Undernutrition in anorexia nervosa leads to decreased levels of the sex hormones critical for bone development.

Low BMD occurs at all skeletal sites in patients with anorexia nervosa, affecting both trabecular and cortical bone. The spine is more likely to be affected than the hip, said Dr. Crawford.

In addition to decreased BMD, another factor that contributes to bone fragility in patients with anorexia nervosa is decreased bone size. Patients with anorexia nervosa develop smaller bones in the vertebral body and femoral neck, compared with normal patients. Consequences of osteoporosis in anorexic patients are stress fractures in weight-bearing bones, and vertebral fractures leading to chronic back pain and reduced height.

Dr. Crawford recommends a routine bone density scan in all patients with anorexia nervosa at disease onset and at least every 2 years thereafter. Restoration of normal weight can improve BMD in anorexic patients, but bone loss may continue, with bone restoration taking at least 21 months. “Overall, data [suggest] despite improvement there are permanent deficits in BMD, underscoring the importance of timely diagnosis and treatment,” she said.

Bisphosphonates are not approved for treatment of premenopausal women. Moreover, the increased bone turnover that occurs normally during adolescence makes the use of bisphosphonates especially controversial for patients in that age group.

Although adequate calcium and vitamin D intake should be provided to patients with anorexia nervosa, supplementation with calcium and vitamin does not increase BMD in anorexic patients. Some evidence suggests that a combination of twice-daily IGF-I administration and estrogen-progesterone treatment may be effective in increasing BMD in anorexic women. Androgen replacement studies have shown conflicting results.

Normally, patients with osteoporosis are advised to engage in weight-bearing exercise such as walking, stair climbing, and weight lifting. However, for patients with anorexia nervosa, the potential benefits of exercise might be offset by the risk of fractures, delayed weight gain, and exercise-induced amenorrhea.

'Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life.' DR. CRAWFORD

TAMPA – Anorexia nervosa reduces bone mass and puts young women at risk for early onset of osteoporosis, just at the time when they should be building peak bone mass, Dr. Steven Crawford said at the annual meeting of the International Society for Clinical Densitometry.

Anorexia nervosa is one of the most common psychiatric diagnoses in adolescent women, with the age of onset showing bimodal peaks at age 14 and 18 years.

Health consequences can be severe. In addition to loss of bone density, patients can suffer cardiovascular problems, muscle loss and weakness, severe dehydration, anemia, and leukopenia. Female patients with anorexia nervosa are amenorrheic. Anorexia nervosa leads to a sevenfold increase in fracture risk. Of adult women with anorexia nervosa, 38% have osteoporosis, and 50% have a bone mineral density (BMD) level below the fracture threshold.

The extent of bone damage is directly affected by the severity of malnutrition and the disease duration. Consequences are more severe when disease onset occurs during the time of peak bone development. Approximately 60% of total bone mass is attained in the growth spurt that normally occurs in adolescence, and skeletal growth essentially is complete by age 18.

“Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life, even when the duration of illness is comparable,” said Dr. Crawford, a clinical psychiatrist at the Center for Eating Disorders, Sheppard Pratt Health System, Baltimore.

Pathophysiology of low bone density in anorexia nervosa results from multiple factors, including undernutrition, hypogonadism, altered levels of bone-essential hormones and growth factors, excessive exercise, and hypercortisolism, among others. Undernutrition in anorexia nervosa leads to decreased levels of the sex hormones critical for bone development.

Low BMD occurs at all skeletal sites in patients with anorexia nervosa, affecting both trabecular and cortical bone. The spine is more likely to be affected than the hip, said Dr. Crawford.

In addition to decreased BMD, another factor that contributes to bone fragility in patients with anorexia nervosa is decreased bone size. Patients with anorexia nervosa develop smaller bones in the vertebral body and femoral neck, compared with normal patients. Consequences of osteoporosis in anorexic patients are stress fractures in weight-bearing bones, and vertebral fractures leading to chronic back pain and reduced height.

Dr. Crawford recommends a routine bone density scan in all patients with anorexia nervosa at disease onset and at least every 2 years thereafter. Restoration of normal weight can improve BMD in anorexic patients, but bone loss may continue, with bone restoration taking at least 21 months. “Overall, data [suggest] despite improvement there are permanent deficits in BMD, underscoring the importance of timely diagnosis and treatment,” she said.

Bisphosphonates are not approved for treatment of premenopausal women. Moreover, the increased bone turnover that occurs normally during adolescence makes the use of bisphosphonates especially controversial for patients in that age group.

Although adequate calcium and vitamin D intake should be provided to patients with anorexia nervosa, supplementation with calcium and vitamin does not increase BMD in anorexic patients. Some evidence suggests that a combination of twice-daily IGF-I administration and estrogen-progesterone treatment may be effective in increasing BMD in anorexic women. Androgen replacement studies have shown conflicting results.

Normally, patients with osteoporosis are advised to engage in weight-bearing exercise such as walking, stair climbing, and weight lifting. However, for patients with anorexia nervosa, the potential benefits of exercise might be offset by the risk of fractures, delayed weight gain, and exercise-induced amenorrhea.

'Bone mineral density is lower when anorexia nervosa begins in adolescence than when it occurs in adult life.' DR. CRAWFORD

New consensus guidelines could help primary care physicians, emergency physicians, and hospitalists better manage community-acquired pneumonia in immunocompetent adults.

A joint committee of the Infectious Diseases Society of America and the American Thoracic Society developed the treatment guidelines, which emphasized that they should be modified according to local epidemiology and susceptibility data (Clin. Infect. Dis. 2007;44:S27–72).

The main differences between the consensus guidelines and earlier management guidelines “center on issues of etiology, the site of care decisions, and diagnosis,” Dr. Lionel A. Mandell said in an interview. Dr. Mandell is professor of medicine at McMaster University, Hamilton, Ont., and is the corresponding author of the guidelines publication.

“In terms of etiology, community-acquired MRSA [methicillin-resistant Staphylococcus aureus] has now become an issue,” he explained. “For the site of care decision, the CURB-65 [confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater] criteria are now recommended as well as the PSI [Pneumonia Severity Index] criteria.”

▸ Site-of-care selection. Assessment of disease severity is the most critical initial decision in management of community-acquired pneumonia (CAP), with an immediate effect on the site of care selection.

The guidelines identify the site of care decision as one area in which CAP management could be improved: “Physicians often admit patients to the hospital who could be well managed as outpatients and who would generally prefer to be treated as outpatients.” To help clinicians evaluate CAP disease severity and determine the most appropriate site of care, the IDSA/ATS Consensus Guidelines recommend the use of severity of illness scores such as CURB-65 and PSI. The three site of care options are outpatient treatment, hospitalization in a medical ward, or admission to an ICU.

In general, patients at low risk for death should be treated in an outpatient setting. Inpatient care increases treatment costs considerably, and unnecessary admissions to the ICU or medical wards may tie up limited hospital resources. In addition, hospitalization increases the risk of thromboembolic events and superinfection by more virulent bacterial strains. However, clinicians must take into account subjective factors, such as the patient's ability to take oral medication safely and reliably, and the support resources available to the patient in an outpatient setting.

▸ ICU admission. The consensus guidelines offer a new set of criteria for the ICU admission decision, while retaining the format of the earlier ATS guidelines.

The guidelines distinguish between patients meeting major admission criteria (strong recommendation for ICU admission) and those meeting three or more minor admission criteria (moderate recommendation for admission).

Direct admission to an ICU is strongly recommended for patients in septic shock requiring vasopressors or with acute respiratory failure requiring mechanical ventilation. Direct admission to an ICU is moderately recommended for patients who meet at least three of these criteria: respiratory rate of 30 breaths/min or higher, arterial oxygen pressure/fraction of inspired oxygen ratio of 250 or lower, multilobar infiltrates, confusion/disorientation, BUN level of 20 mg/dL or higher, WBC count less than 4,000 cells/mcL, platelet count less than 100,000 cells/mcL, core temperature below 36° C, and hypotension requiring fluid resuscitation.

▸ Antibiotics. Empirical antibiotic recommendations do not differ substantially from earlier ones. Additional clinical evidence now supports combination antibiotic therapy for severe CAP, and ertapenem is included as a β-lactam alternative recommended under some circumstances.

▸ Diagnosis and testing. Diagnosis of pneumonia is made based on clinical symptoms and evidence of an infiltrate in the lungs, usually from images obtained by chest radiography or other technique.

The issue of diagnostic testing to determine etiology remains controversial. “Blood cultures and Gram stain and culture of respiratory secretions are not recommended for all hospital admissions,” Dr. Mandell said. If the clinician suspects infection with specific pathogens that would require a change in the empirical antibiotic regimen, testing for CAP etiology is recommended. If sputum samples are collected, ideally the samples should be obtained before antibiotic therapy is initiated. Gram stains of sputum samples may guide initial antimicrobial therapy and validate later sputum culture results.

Severe CAP is an indication for blood cultures, because of the increased possibility that an unusual pathogen may be detected. Pretreatment blood and sputum cultures also are appropriate for hospitalized patients with risk factors such as asplenia, which would lead to an inability to clear bacteremia, or with comorbid conditions associated with increased likelihood of bacteremia with CAP, such as chronic liver disease or leucopenia.

Alcoholism and chronic obstructive pulmonary disease are major risk factors for infection with gram-negative pathogens such as Pseudomonas aeruginosa; blood and sputum cultures may be appropriate in patients with those conditions.

The guidelines are available as a free down-load at www.journals.uchicago.edu/CID/journal/issues/v44nS2/41620/41620.html

New consensus guidelines could help primary care physicians, emergency physicians, and hospitalists better manage community-acquired pneumonia in immunocompetent adults.

A joint committee of the Infectious Diseases Society of America and the American Thoracic Society developed the treatment guidelines, which emphasized that they should be modified according to local epidemiology and susceptibility data (Clin. Infect. Dis. 2007;44:S27–72).

The main differences between the consensus guidelines and earlier management guidelines “center on issues of etiology, the site of care decisions, and diagnosis,” Dr. Lionel A. Mandell said in an interview. Dr. Mandell is professor of medicine at McMaster University, Hamilton, Ont., and is the corresponding author of the guidelines publication.

“In terms of etiology, community-acquired MRSA [methicillin-resistant Staphylococcus aureus] has now become an issue,” he explained. “For the site of care decision, the CURB-65 [confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater] criteria are now recommended as well as the PSI [Pneumonia Severity Index] criteria.”

▸ Site-of-care selection. Assessment of disease severity is the most critical initial decision in management of community-acquired pneumonia (CAP), with an immediate effect on the site of care selection.

The guidelines identify the site of care decision as one area in which CAP management could be improved: “Physicians often admit patients to the hospital who could be well managed as outpatients and who would generally prefer to be treated as outpatients.” To help clinicians evaluate CAP disease severity and determine the most appropriate site of care, the IDSA/ATS Consensus Guidelines recommend the use of severity of illness scores such as CURB-65 and PSI. The three site of care options are outpatient treatment, hospitalization in a medical ward, or admission to an ICU.

In general, patients at low risk for death should be treated in an outpatient setting. Inpatient care increases treatment costs considerably, and unnecessary admissions to the ICU or medical wards may tie up limited hospital resources. In addition, hospitalization increases the risk of thromboembolic events and superinfection by more virulent bacterial strains. However, clinicians must take into account subjective factors, such as the patient's ability to take oral medication safely and reliably, and the support resources available to the patient in an outpatient setting.

▸ ICU admission. The consensus guidelines offer a new set of criteria for the ICU admission decision, while retaining the format of the earlier ATS guidelines.

The guidelines distinguish between patients meeting major admission criteria (strong recommendation for ICU admission) and those meeting three or more minor admission criteria (moderate recommendation for admission).

Direct admission to an ICU is strongly recommended for patients in septic shock requiring vasopressors or with acute respiratory failure requiring mechanical ventilation. Direct admission to an ICU is moderately recommended for patients who meet at least three of these criteria: respiratory rate of 30 breaths/min or higher, arterial oxygen pressure/fraction of inspired oxygen ratio of 250 or lower, multilobar infiltrates, confusion/disorientation, BUN level of 20 mg/dL or higher, WBC count less than 4,000 cells/mcL, platelet count less than 100,000 cells/mcL, core temperature below 36° C, and hypotension requiring fluid resuscitation.

▸ Antibiotics. Empirical antibiotic recommendations do not differ substantially from earlier ones. Additional clinical evidence now supports combination antibiotic therapy for severe CAP, and ertapenem is included as a β-lactam alternative recommended under some circumstances.

▸ Diagnosis and testing. Diagnosis of pneumonia is made based on clinical symptoms and evidence of an infiltrate in the lungs, usually from images obtained by chest radiography or other technique.

The issue of diagnostic testing to determine etiology remains controversial. “Blood cultures and Gram stain and culture of respiratory secretions are not recommended for all hospital admissions,” Dr. Mandell said. If the clinician suspects infection with specific pathogens that would require a change in the empirical antibiotic regimen, testing for CAP etiology is recommended. If sputum samples are collected, ideally the samples should be obtained before antibiotic therapy is initiated. Gram stains of sputum samples may guide initial antimicrobial therapy and validate later sputum culture results.

Severe CAP is an indication for blood cultures, because of the increased possibility that an unusual pathogen may be detected. Pretreatment blood and sputum cultures also are appropriate for hospitalized patients with risk factors such as asplenia, which would lead to an inability to clear bacteremia, or with comorbid conditions associated with increased likelihood of bacteremia with CAP, such as chronic liver disease or leucopenia.

Alcoholism and chronic obstructive pulmonary disease are major risk factors for infection with gram-negative pathogens such as Pseudomonas aeruginosa; blood and sputum cultures may be appropriate in patients with those conditions.

The guidelines are available as a free down-load at www.journals.uchicago.edu/CID/journal/issues/v44nS2/41620/41620.html

New consensus guidelines could help primary care physicians, emergency physicians, and hospitalists better manage community-acquired pneumonia in immunocompetent adults.

A joint committee of the Infectious Diseases Society of America and the American Thoracic Society developed the treatment guidelines, which emphasized that they should be modified according to local epidemiology and susceptibility data (Clin. Infect. Dis. 2007;44:S27–72).

The main differences between the consensus guidelines and earlier management guidelines “center on issues of etiology, the site of care decisions, and diagnosis,” Dr. Lionel A. Mandell said in an interview. Dr. Mandell is professor of medicine at McMaster University, Hamilton, Ont., and is the corresponding author of the guidelines publication.

“In terms of etiology, community-acquired MRSA [methicillin-resistant Staphylococcus aureus] has now become an issue,” he explained. “For the site of care decision, the CURB-65 [confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater] criteria are now recommended as well as the PSI [Pneumonia Severity Index] criteria.”

▸ Site-of-care selection. Assessment of disease severity is the most critical initial decision in management of community-acquired pneumonia (CAP), with an immediate effect on the site of care selection.

The guidelines identify the site of care decision as one area in which CAP management could be improved: “Physicians often admit patients to the hospital who could be well managed as outpatients and who would generally prefer to be treated as outpatients.” To help clinicians evaluate CAP disease severity and determine the most appropriate site of care, the IDSA/ATS Consensus Guidelines recommend the use of severity of illness scores such as CURB-65 and PSI. The three site of care options are outpatient treatment, hospitalization in a medical ward, or admission to an ICU.

In general, patients at low risk for death should be treated in an outpatient setting. Inpatient care increases treatment costs considerably, and unnecessary admissions to the ICU or medical wards may tie up limited hospital resources. In addition, hospitalization increases the risk of thromboembolic events and superinfection by more virulent bacterial strains. However, clinicians must take into account subjective factors, such as the patient's ability to take oral medication safely and reliably, and the support resources available to the patient in an outpatient setting.

▸ ICU admission. The consensus guidelines offer a new set of criteria for the ICU admission decision, while retaining the format of the earlier ATS guidelines.

The guidelines distinguish between patients meeting major admission criteria (strong recommendation for ICU admission) and those meeting three or more minor admission criteria (moderate recommendation for admission).

Direct admission to an ICU is strongly recommended for patients in septic shock requiring vasopressors or with acute respiratory failure requiring mechanical ventilation. Direct admission to an ICU is moderately recommended for patients who meet at least three of these criteria: respiratory rate of 30 breaths/min or higher, arterial oxygen pressure/fraction of inspired oxygen ratio of 250 or lower, multilobar infiltrates, confusion/disorientation, BUN level of 20 mg/dL or higher, WBC count less than 4,000 cells/mcL, platelet count less than 100,000 cells/mcL, core temperature below 36° C, and hypotension requiring fluid resuscitation.

▸ Antibiotics. Empirical antibiotic recommendations do not differ substantially from earlier ones. Additional clinical evidence now supports combination antibiotic therapy for severe CAP, and ertapenem is included as a β-lactam alternative recommended under some circumstances.

▸ Diagnosis and testing. Diagnosis of pneumonia is made based on clinical symptoms and evidence of an infiltrate in the lungs, usually from images obtained by chest radiography or other technique.

The issue of diagnostic testing to determine etiology remains controversial. “Blood cultures and Gram stain and culture of respiratory secretions are not recommended for all hospital admissions,” Dr. Mandell said. If the clinician suspects infection with specific pathogens that would require a change in the empirical antibiotic regimen, testing for CAP etiology is recommended. If sputum samples are collected, ideally the samples should be obtained before antibiotic therapy is initiated. Gram stains of sputum samples may guide initial antimicrobial therapy and validate later sputum culture results.

Severe CAP is an indication for blood cultures, because of the increased possibility that an unusual pathogen may be detected. Pretreatment blood and sputum cultures also are appropriate for hospitalized patients with risk factors such as asplenia, which would lead to an inability to clear bacteremia, or with comorbid conditions associated with increased likelihood of bacteremia with CAP, such as chronic liver disease or leucopenia.

Alcoholism and chronic obstructive pulmonary disease are major risk factors for infection with gram-negative pathogens such as Pseudomonas aeruginosa; blood and sputum cultures may be appropriate in patients with those conditions.

The guidelines are available as a free down-load at www.journals.uchicago.edu/CID/journal/issues/v44nS2/41620/41620.html