Summary.It is unknown whether bone changes which can occur in multiple myeloma (MM) are due to cytokineinduced osteoclastic bone resorption from a clone of abnormal plasma cells or high-dose glucocorticoid therapy.We studied 25 MM patients treated for 1-12 years with combination chemotherapy, subdivided into two groups. Group 1 consisted of 12 patients with stage I and II myeloma and group 2 consisted of 13 patients with stage III MM. Their serum biochemistry, tetracycline-labelled bone histomorphometry and bone densitometry were compared to age-and sex-matched controls.Patients with MM demonstrated increased indices of bone resorption (P < 0 : 001 versus controls) and, to a lesser extent, increased indices of bone formation (P < 0 : 01 versus controls). No patient had evidence of a mineralization defect.Lumbar spine, femoral neck and total body bone mineral density measurements (BMD) were significantly lower in group 2 compared with group 1 (P < 0 : 05). Following 12 months of therapy, lumbar spine BMD decreased by 6 : 6% (95% CI, 2 : 7% to ¹9 : 3%) and femoral neck BMD decreased by 9 : 5% (95% CI, ¹3 : 2% to ¹15 : 9%). In a stepwise regression analysis, cumulative prednisolone dosage (B Coef: ¼ ¹0 : 39; P ¼ 0 : 03) and plasma cell infiltrate (B Coef: ¼ ¹0 : 08; P ¼ 0 : 05) were the most important predictors of lumbar spine bone loss, whereas serum paraprotein (B Coef: ¼ ¹0 : 35; P ¼ 0 : 02) and plasma cell infiltrate (B Coef: ¼ ¹0 : 20; P ¼ 0 : 04) were the most important predictors of femoral neck bone loss.We conclude that MM is characterized by high bone turnover with osteoblast-osteoclast uncoupling. Both disease activity and high-dose glucocorticoid therapy may be responsible for the ongoing bone loss seen with MM.

Parathyroid surgery is indicated in patients presenting with primary hyperparathyroidism (PHPT) and osteoporosis (defined as bone mineral density more than 2 standard deviations below normal). Many are elderly women with complex medical problems, either unwilling or considered unfit for surgery. Estrogen replacement therapy (ERT) may potentially be an alternative form of therapy in this group. We studied 15 consecutive postmenopausal women presenting with PHPT and osteoporosis. Group 1 comprised 5 women who elected to be treated with ERT (conjugated equine estrogen, 0.3-0.625 mg/day). The other 10 women underwent successful parathyroidectomy. These 10 patients were randomly subdivided into group 2 (5 patients who received calcitriol 0.25 micrograms b.i.d. for 12 months following surgery) and group 3 (5 patients who received elemental calcium 1 g/day for 12 months following surgery). Lumbar spine and femoral neck bone mineral density (BMD) were measured prior to and after 12 months of therapy, using a dual-energy X-ray absorptiometer (Lunar DPX-L). The three groups did not differ with respect to their ages (group mean 71.8 years), or baseline serum calcium (group mean 2.77 mmol/l), serum parathyroid hormone (group mean 11.0 pmol/l), lumbar spine BMD (group mean 0.93 g/cm2) and femoral neck BMD (group mean 0.73 g/cm2). Serum calcium normalized in all patients who underwent surgery and none developed hypoparathyroidism. A non-significant decrease in serum calcium was seen in patients treated with ERT only. Lumbar spine (+5.3% per year; 95% CI, 1.1% to 9.6%) and femoral neck BMD (+5.5% per year; 95% CI, -2.1% to 13.2%) increased significantly after 12 months of ERT (p < 0.001 compared with pre-therapy values). These increases in BMD did not differ significantly from those in patients who underwent successful parathyroidectomy followed by either calcitriol therapy or calcium replacement (lumbar spine BMD increase of +6.2% per year, 95% CI 3.1% to 9.4%; and femoral neck BMD increase of +3% per year, 95% CI 0 to 6%). In summary, increases in lumbar spine and femoral neck BMD occur following treatment of PHPT. ERT appeared as effective as parathyroidectomy (combined with either calcitriol or calcium supplements) for the treatment of osteoporosis in elderly postmenopausal women presenting with PHPT.

CHRONIC VITAMIN D DEFICIENCY may lead to osteomalacia and/or osteoporosis, with an increased risk of fragility fractures. 1 In Australia, with its multicultural population, a resurgence of vitamin D deficiency has been noted recently. 2 While there are reports of abnormalities in vitamin D metabolism in Muslim women, 3,4 there are no published data on fracture rates, bone mass measurements or bone turnover rates in this cohort. We aimed to determine the effect of vitamin D deficiency on bone turnover in Muslim women. METHODS 1.Methods ParticipantsMuslim women aged 20-65 years were invited to participate in our study through a pamphlet questionnaire, which was distributed in shopping centres and mosques in south-western Sydney in November 1999 to April 2000. We used a simple format with "yes or no" answers to obtain details about their (i) dress (whether they were veiled during daily outdoor activities), (ii) sun exposure (defined as more or less than 60 minutes of daily, outdoor sunlight exposure per week), and (iii) menopausal status. They were also asked to donate venous blood and to collect an early-morning, two-hour urine sample for analysis. Recruitment was undertaken during the summer months.We excluded from the study women who refused phlebotomy, had chronic medical disorders or were receiving medications that could interfere with bone turnover. Informed consent was obtained from all participants. Our ABSTRACT Objective: To measure bone turnover in Muslim women with vitamin D deficiency. Design: A cross-sectional study of a random sample of Muslim women aged 20-65 years, evaluated over a 6-month period from November 1999 to April 2000. Setting and participants: 146 women living in an urban community in southwestern Sydney with adequate opportunities for sun exposure. Main outcome measures: Bone turnover as measured by urinary deoxypyridinoline (DPYD) excretion rates; and vitamin D status as determined by 25-hydroxyvitamin D (25OHD) levels, serum calcium levels and parathyroid hormone (PTH) concentrations. Results: We analysed data on 119 Muslim women (mean [SEM] age, 46.6 [1.1] years) who met the inclusion criteria. There were 81 (68.1%) women with serum 25OHD levels < 30 nmol/L (defined as "severe" vitamin D deficiency). Fifty-five (46.2%) women had evidence of high bone turnover (urinary DPYD excretion > 6.5 nmol/mmol creatinine). The women with "severe" vitamin D deficiency had significantly higher serum PTH levels (7.3 [0.3] v 5.4 [0.5] pmol/L; P = 0.001) and higher urinary DPYD excretion (7.2 [0.3] v 5.4 [0.2] nmol/mmol creatinine; P = 0.003) than women with serum 25OHD levels у 30 nmol/L. No significant differences were seen in their ages, menopausal status or serum calcium and phosphate measurements. The risk of developing high bone turnover was significantly greater in the women with "severe" vitamin D deficiency (relative risk = 5.52; 95% CI, 2-14.8; 2 = 12.95; P = 0.0003). Conclusion: High bone turnover occurs in Muslim women with vitamin D MJA 2002; 177: 139-141 deficiency.