Ca&Bone

[Disturbances of the bone metabolism in type 1 diabetic patients]

KERÉNYI ZSUZSA1, TAMÁS GYULA2, TABÁK Gy. Ádám3, SPEIZER SZABINA4, SPEER Gábor, MÉSZÁROS SZILVIA3, LAKATOS Péter3, HORVÁTH CSABA3

FEBRUARY 14, 2007

Ca&Bone - 2007;10(01)

[AIMS - Because of contradictory data in literature our aim was to study bone metabolic disturbances and their correlates with anthropometric and metabolic parameters in type 1 diabetic patients (T1DM). Since quantitative bone ultrasound (QUS) measures bone qualities different from BMD, and it has only been scarcely investigated in T1DM, our aim was to describe covariates of QUS parameters. PATIENTS AND METHODS - Osteodensitometry was performed (lumbal spine, femur neck - DEXA; calcaneal ultrasound) on 115 T1DM patients (34 male, 81 female; mean age: 41.4±11 [± SD] yrs; BMI: 23.9±3.0 kg/m2; diabetes duration: 21.6±11.7 yrs; HbA1c: 8.1±1.3%). In addition anthropometric, blood pressure and laboratory parameters (HbA1c, lipids, renal function, fibrinogen, homocystein, PTH, TSH, β-CrossLaps, vitamine D3, osteocalcin, osteoprotegerin) were measured, data using a questionnaire were collected. RESULTS - The prevalence of osteoporosis was 9/112 (8%). A further 21/62 patients with osteopenia were found. Disturbances of bone metabolism have been more frequently proven on lumbal spine (p<0.001). Using multiple linear regression modelling, the independent covariates of osteopathy were systolic blood pressure, body weight, β-CrossLaps and cystatin C. The average broadband ultrasound attenuation (BUA) was 114.2±14.9 in males vs. 108.4±16.3 dB/MHz in females (p=0.07), the mean speed of sound (SOS) 1552±26 in males vs. 1559±32 m/s in females (p=0.32). SOS values in addition to bone density were associated with fracture risk. The independent covariates of BUA were body weight and height (R=0.473, p<0.001), and of SOS only fibrinogen (R=0.305, p=0.032). CONCLUSIONS - According to our results the prevalence of osteoporosis in acceptable controlled T1DM patients is relatively low. The more common metabolic calcipenic osteopathy show a correlation with body weight, markers of bone resorption and diabetic complications/co-morbidities (nephropathy, hypertension) being therefore not only an a priori consequence but also a complication of diabetes mellitus. Our data provide baseline data of QUS in type 1 diabetic patients. Because of the frequency of lower bone mineral content and their known high fracture risk bone metabolism screening of T1DM patients has to be considered.]

AFFILIATIONS

  1. Csepeli Egészségügyi Szolgálat, Diabetológia, Diabétesz Gondozási Nemzeti Központ
  2. Semmelweis Egyetem, Általános Orvostudományi Kar, I. Sz. Belgyógyászati Klinika, Diabétesz Gondozási Nemzeti Központ
  3. Semmelweis Egyetem, Általános Orvostudományi Kar, I. Sz. Belgyógyászati Klinika
  4. Fôvárosi Önkormányzat Károlyi Kórház, I. Sz. Belgyógyászati Osztály

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[The influence of menopause-related obesity and related changes of body fat distribution on the severity of sleep apnea]

GYŐRFI MÁRIA, SANDRA SÁNDOR, SZAKÁCS ZOLTÁN

[INTRODUCTION - The menopause is associated with an enhanced risk of obesity. During the postmenopausal period changes in the distribution of body fat lead to a variety of disorders. Obesity is among the major risk factors for Obstructive Sleep Apnea Syndrome (OSAS). The prevalence of OSAS increases after the menopause. This study was intended to explore the relationship between the severity of sleep apnea and the quantity, as well as the distribution of body fat in postmenopausal women with this condition. PATIENTS AND METHODS - Sixty-two postmenopausal women (aged 58.6±7.4 years) were studied. Patients suffering from OSAS - established by cardiorespiratory polygraphy - were enrolled. None of the subjects received hormone replacement therapy during the trial. Total and regional quantity of body fat was determined by dualenergy X-ray absorptiometry (DXA). The distribution of body fat, the ratio of android-to-gynoid regional fat, as well as body mass index were automatically calculated by the software of the DXA machine. A specific region was defined to measure the fat content of the cervical region, extending from the mental protuberance to the clavicular plane. The reliability coefficient of the test method was calculated to check the accuracy of regional body fat measurement. The severity of obstructive sleep apnea was determined by cardiorespiratory polygraphy and expressed using the apnea/hypopnea index. RESULTS - Testing for independence in this population revealed the lack of independence between android-type obesity and severe OSAS. Specifically, 74% of patients with severe OSAS were obese (BMI>30 kg/m2). As with the android-type, the khi square test similarly refuted the independence between obesity and the severity of OSAS. Fat content of the cervical region was 25.2% in mild and moderate, and 30.2% in severe OSAS. Two-Sample t-test demonstrated the significant influence of cervical fat content on OSAS severity. CONCLUSION - Elevated BMI, android-type obesity, and higher relative fat content of the cervical region all aggravate obstructive sleep apnea in postmenopausal women.]

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[Dear Readers and Colleagues!]

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[Higher bone fracture prevalence in postmenopausal pollen allergic women]

FERENCZ VIKTÓRIA, MÉSZÁROS SZILVIA, CSUPOR EMŐKE, TÓTH EDIT, BORS Katalin, FALUS ANDRÁS, HORVÁTH CSABA

[Our aim was to investigate whether pollen allergy can affect bone mass and fractures in postmenopausal women. A total of 125 postmenopausal pollen allergic women (mean age 61.26 years) were split into four groups: treated neither with H1 histamine receptor (H1R) antagonist nor with inhaled corticosteroid (n=43), treated only with H1R antagonist (n=53), treated both with H1R antagonist and inhaled corticosteroid (n=17), treated only with inhaled corticosteroid (n=12) for at least five years, seasonally. One-hundred non-allergic postmenopausal subjects matched for age, body mass index (BMI) and age at menopause served as controls. Overweight and obesity (25 kg/m2 ≤ BMI) were common among allergic women (76%). Allergic patients without treatment had a slightly lower bone density than their non-allergic mates. Untreated allergic had almost triple the rate of prevalent low-energy fractures (distal forearm, hip and clinical vertebral fractures: 34.9%) compared to non-allergic women (13%, χ2 p=0.003). Bone fracture occurred more often in H1R-only treated patients (30.19%) than in controls (χ2 p=0.01), however, clinical vertebral or hip fractures developed neither in those treated only with H1R antagonist nor in those who received both H1R antagonist and inhaled corticosteroid. Bone fractures were more frequent among patients with inhaled steroid treatment than among patients with a combined treatment of inhaled steroid and antihistamine (50% vs. 29.4%). BMI predicted prevalent fractures at 1.278 (95% CI, 1.047 to 1.559, p=0.016) for 1 kg/m2 increase among untreated allergic patients. In conclusion we found a high prevalence of low-energy fractures among pollen-allergic postmenopausal women, which was associated with obesity. It is possible that the H1R antagonists compensate for the negative effect of pollen-allergy and the adverse effect of inhaled corticosteroid treatment on bone fracture risk.]

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[Possibilities of applying basis/bolus method in treatment of adolescent with type 1 diabetes mellitus]

BLATNICZKY László

[INTRODUCTION - Since the end of the pastcentury, the basis/bolus method has been adeterminate factor of adjusting insulin thera-py. Experiences with insulin pump treatmentprove that well-quantified and adequatelytimed basal insulin treatment can fully com-pensate for the diurnal glucose-producingactivities of the liver and the diurnal changesin the activity of insulin receptors. Suitablyselected basal insulin treatment can, there-fore, keep the changes in blood sugar levelthat are dependent of the diet’s carbohydratecontent well under control. CASE REPORT - By presenting the approxi-mately five-year treatment of an adolescentboy, the author presents the current options(and failures) of insulin therapy that might beused with more or less success. Each treat-ment approach had its place in the variousstages of the patient’s diabetes. Nevertheless,insulin pump therapy, admittedly the moststate-of-the-art method today was unsuccess-ful due to patient’s lack of compliance, thusthis treatment had to be stopped. Still, on thebasis of the experiences with insulin pumptherapy, the restored intensive-conservativetreatment was set up on glargine basalinsulin, defining doses of bolus in correlationwith 10 grams of carbohydrate, which madethe diet less strict. This approach resulted ina considerable improvement of the patient’smetabolic profile. CONCLUSION - The right choice of thedoses and efficacy curve of basal insulin isessential for achieving a good metabolic bal-ance during intensive-conservative therapy.In case of deteriorating metabolic balance,suspending the inefficient insulin pump ther-apy is justified and means no disadvantagefor the patient, as long as the subsequentadjustment is prudent. By defining doses of ashort-acting bolus insulin analogue in corre-lation with carbohydrate intake along withglargine therapy permits adaptation to themetabolism of patients with poor compli-ance and unsatisfactory lifestyle - in expec-tation of better results. ]

Ca&Bone

[Significance of quantitative ultrasound bone densitometry and its introduction into pediatric bone medicine]

HOSSZÚ ÉVA, HAZAY Máté, LIPTOVSZKY Janka

[INTRODUCTION - Quantitative Ultrasound (QUS) examination of the bones provides information about not only bone mineral mass but also its quality. Adaptation of the method to the continuous growing of body size allowed its pediatric use. However, for introduction into routine use, a normal reference range in healthy children has to be established. The primary aim of this study was to establish the Hungarian reference range for QUS of the bone - in both genders and across a wide range of ages. As a secondary aim, QUS and the bone density were compared to internationally accepted data to comparatively determine correlations of specific QUS measurements to photon absorption based values. SUBJECTS AND METHODS - Measurement was performed on the calcaneus by Achilles Insight (Lunar, WI) device. Bone Mineral Density (BMD) of the lumbar spine was measured using the Double X-ray Absorptiometry (DXA) device DPX-L (Lunar, WI). Latter was also used to measure total body calcium content. Measurements were performed in 154 healthy boys and girls aged 5 to 18 years. We analyzed data as a function of age, and correlated results of he two types of measurement. RESULTS - Gender-specific reference ranges for normally developing children of the above ages were built up for Broadband Ultrasound Attenuation (BUA) and Speed of Sound (SOS). BUA showed the best correlation to BMD. SOS and Stiffness Index (SI) derived from BUA and SOS, correlated weaker to BMD, consonantly with the fact that SOS reflects bone elasticity (quality) rather than bone mineral mass. CONCLUSION - These newly constructed normal ranges can provide a basis of performing pediatric bone examinations using QUS, which is less expensive and more mobile.]

Lege Artis Medicinae

[Measurement of coronary artery calcification in adults with type 1 diabetes mellitus using dual-source, multi-slice computed tomography]

MAUROVICH-HORVAT Pál

[INTRODUCTION - Coronary artery calcification can be characterized non-invasively and numerically using computed tomography (CT). In adult patients with type 1 diabetes mellitus, coronary atherosclerosis may be present without clinical symptoms. PATIENTS AND METHODS - Asymptomatic adults with type 1 diabetes mellitus (n=46) were investigated. Coronary artery calcification was expressed in Agatston-scores using a dual source CT scanner. RESULTS - Twenty-one patients had a coronary artery calcification score of ≥1 (range 1-2353), while in 25 patients no detectable calcium (score 0) was observed. Patients with vs. without coronary artery calcification had a higher age (51.0±9.9 vs. 42.8±7.8 years; p=0.0045), a longer duration of diabetes (30.6±9.2 vs. 24.2± 8.6 years; p=0.0238), a higher waist circumference (87.9±11.5 vs. 79.7±9.4 cm; p=0.0146), and a higher BMI (26.2±2.9 vs. 23.8±3.1 kg/m2;p=0.0109). Moreover, patients with vs. without detectable coronary artery calcification had higher serum lipid levels (LDL-cholesterol, 3.35±0.32 vs. 3.01±0.68 mmol/l; p=0.0069) and higher serum uric acid levels (228.4±48.7 vs. 195.1±39.4 µmol/l; p=0.0437). Hypertension was more common (p=0.0144) in patients with coronary artery calcification than in patients without it. There was no significant difference between the groups in HbA1c (7.97±0.85 vs. 8.26±1.28%; p=0.7491), however, estimated insulin sensitivity was lower in patients with vs. without detectable coronary artery calcification (7.15±2.09 vs. 9.20±2.03 mg/kg/min; p=0.0017). CONCLUSION - Our results suggest that coronary artery disease in type 1 diabetic patients is associated with higher age, longer duration of diabetes, and cardiovascular risk factors rather than with long-term glucose control.]

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[Asserting basis-bolus principle by analogue insulin preparations in pre-pubertal child with diabetes]

BLATNICZKY László

[INTRODUCTION - The choice of insulin combination therapy in children with type 1 diabetes mellitus is determined basically by the diet as well as the age of the patient. However, life rhythms of individual children are widely different. As a consequence, insulin therapy must be tailored to individual needs, by chosing the optimal one from the available insulin products with different efficacy curves. The aim is, of course, to maintain near-normoglycaemia for years or decades. CASE STUDY - The author presents the case of a 10-year-old girl with diabetes for 4 years, whose insulin treatment has involved a number of combinations. Good metabolic balance could be obtained by premixed insulin preparations for more than two years. However, subsequent intensive treatment with human insulins had poor results. This was primarily due to the fact that the child had a rather hectic daily schedule and eating habits, although she ate - appropriately for her age - six meals per day. After changing the ratios of the meals while maintaining her six-mealsper- day regime, an analogue glargine/glulisine combination therapy was induced, with a significant increase in the basal/ bolus ratio. This treatment was successful: HbA1c level got to the target range, without changes - theoretically caused by the rapid analogue - in hypo- and hyperglycaemic periods before and after small meals, respectively. CONCLUSION - During the time of remission, treatment with premixed human insulin can maintain good metabolic balance even for years, while saving (at least) two pricks per day. Insulin treatment intensified by analogue insulins (glulisine/glargine) may be attempted in prepubertal children needing six meals a day, provided their lifestyle raises problems. Glargine, given in an increased ratio, can compensate the hyperglycaemic effect of minimised small meals.]

Ca&Bone

[Serum 25(OH)-Vitamin D levels and bone metabolism in patients on maintenance hemodialysis]

ALMÁSI Csilla, AMBRUS Csaba, DEÁK György, MARTON Adrienn, BERTA Klára, LAKATOS Péter, SZABÓ András, HORVÁTH CSABA, MUCSI István

[INTRODUCTION - Increasing evidence suggests that 25- hydroxy vitamin D3 (25(OH)D3) may contribute to the bone health of patients with chronic kidney disease.However, there is very little information available on the vitamin D3 status of patients with chronic renal failure. In a cross-sectional study we assessed the association between vitamin D3 status and parathyroid function, bone turnover, bone mass and structure in patients on maintenance haemodialysis. PATIENTS AND METHODS - Sixty-nine patients on maintenance haemodialysis were assessed by bone densitometry (DEXA) and quantitative bone ultrasound. Serum 25-hydroxy vitamin D3 levels and serum markers of bone turnover were simultaneously measured. RESULTS - A high prevalence of potentially significant vitamin D3 deficiency was found in this patient group; 59% of the patients had their 25(OH)D3 vitamin level below 20 nmol/l.There was a significant negative correlation between serum 25(OH)D3 and serum intact parathormone (iPTH) levels (r=-0.231, p<0.05) and this association remained significant after controlling for potential co-variables. Furthermore, a positive correlation was observed between serum 25(OH)D3 concentration and bone mineral density measured at the radius (r=0.424, p<0.01). Finally,we show for the first time that 25(OH)D3 levels are significantly and independently associated with broad band ultrasound attenuation (β =0.237, p<0.05) measured with calcaneal quantitative bone ultrasound in patients with chronic renal failure. CONCLUSION - Vitamin D3 deficiency may contribute to the impaired bone health of patients on maintenance dialysis, therefore, it seems to be warranted regularly monitoring and carefully controlling the D3-vitamin level of these patients.The results also suggest that quantitative bone ultrasound is useful in assessing bone health of patients with chronic renal failure.]