Dual-Energy X-Ray Absorptiometry And Calculated Frax Risk Scores May Underestimate Osteoporotic Fracture Risk In Vitamin D-Deficient Veterans With Hiv Infection

Objective: We evaluated the utility of the Fracture Risk Assessment Tool (FRAX) in assessing fracture risk in patients with human immunodeficiency virus (HIV) and vitamin D deficiency.Methods: This was a retrospective study of HIV-infected patients with co-existing vitamin D deficiency at the Atlanta Veterans Affairs Medical Center. Bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry (DEXA), and the 10-year fracture risk was calculated by the FRAX algorithm. Two independent radiologists reviewed lateral chest radiographs for the presence of subclinical vertebral fractures.Results: We identified 232 patients with HIV and vitamin D deficiency. Overall, 15.5% of patients met diagnostic criteria for osteoporosis on DEXA, and 58% had low BMD (T-score between -1 and -2.5). The median risk of any major osteoporotic and hip fracture by FRAX score was 1.45 and 0.10%, respectively. Subclinical vertebral fractures were detected in 46.6% of patients. Compared to those without fractures, those with fractures had similar prevalence of osteoporosis (15.3% versus 15.7%; P>.999), low BMD (53.2% versus 59.3%; P = .419), and similar FRAX hip scores (0.10% versus 0.10%; P = .412). While the FRAX major score was lower in the nonfracture group versus fracture group (1.30% versus 1.60%; P = .025), this was not clinically significant.Conclusion: We found a high prevalence of subclinical vertebral fractures among vitamin D–deficient HIV patients; however, DEXA and FRAX failed to predict those with fractures. Our results suggest that traditional screening tools for fragility fractures may not be applicable to this high-risk patient population.Abbreviations:25(OH)D = 25-hydroxyvitamin DBMD = bone mineral densityBMI = body mass indexDEXA = dual-energy X-ray absorptiometryFRAX = Fracture Risk Assessment ToolHIV = human immunodeficiency virusIQR = interquartile rangePTH = parathyroid hormoneVA = Veterans AffairsWHO = World Health Organization     

Anabolic Therapy and Optimal Treatment Sequences for Patients With Osteoporosis at High Risk for Fracture

Objective: Provide an update regarding anabolic medications for osteoporosis, which are often considered to be the last resort for patients with osteoporosis, after multiple fractures have already occurred and other medications have already been administered.Methods: Literature review and discussion.Results: Recent pivotal trial data for anabolic agents and randomized trials comparing anabolic and antiresorptive medications suggest that three anabolic agents (teriparatide, abaloparatide, and romosozumab) reduce nonvertebral and vertebral fractures faster and to a greater extent than potent antiresorptive treatments. Furthermore, bone density accrual is maximized when patients are given anabolic agents first, followed by potent antiresorptive therapy. Since total hip bone density during or after osteoporosis treatment has emerged as an excellent surrogate for future fracture risk, attaining a greater hip bone mineral density is a treatment goal for high-risk osteoporosis patients.Conclusion: This review defines the highest-risk patients and summarizes the rationale for the evolving role of anabolic therapy in the management of postmenopausal women at high risk for fracture.Abbreviations: ACTIVE = Abaloparatide Comparator Trial in Vertebral Endpoints; ARCH = Active Controlled Fracture Study in Postmenopausal Women with Osteoporosis at High Risk; BMD = bone mineral density; FRAME = Fracture Study in Postmenopausal Women with Osteoporosis; FRAX = Fracture Risk Assessment Tool; PTH = parathyroid hormone; TBS = trabecular bone score     

Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Quality of DXA Scans and Reports

Objective: High-quality dual-energy X-ray absorptiometry (DXA) scans are necessary for accurate diagnosis of osteoporosis and monitoring of therapy; however, DXA scan reports may contain errors that cause confusion about diagnosis and treatment. This American Association of Clinical Endocrinologists/American College of Endocrinology consensus statement was generated to draw attention to many common technical problems affecting DXA report conclusions and provide guidance on how to address them to ensure that patients receive appropriate osteoporosis care.Methods: The DXA Writing Committee developed a consensus based on discussion and evaluation of available literature related to osteoporosis and osteodensitometry.Results: Technical errors may include errors in scan acquisition and/or analysis, leading to incorrect diagnosis and reporting of change over time. Although the International Society for Clinical Densitometry advocates training for technologists and medical interpreters to help eliminate these problems, many lack skill in this technology. Suspicion that reports are wrong arises when clinical history is not compatible with scan interpretation (e.g., dramatic increase/decrease in a short period of time; declines in previously stable bone density after years of treatment), when different scanners are used, or when inconsistent anatomic sites are used for monitoring the response to therapy. Understanding the concept of least significant change will minimize erroneous conclusions about changes in bone density.Conclusion: Clinicians must develop the skills to differentiate technical problems, which confound reports, from real biological changes. We recommend that clinicians review actual scan images and data, instead of relying solely on the impression of the report, to pinpoint errors and accurately interpret DXA scan images.Abbreviations: AACE = American Association of Clinical Endocrinologists; BMC = bone mineral content; BMD = bone mineral density; DXA = dual-energy X-ray absorptiometry; ISCD = International Society for Clinical Densitometry; LSC = least significant change; TBS = trabecular bone score; WHO = World Health Organization     

Frax Prediction without BMD for Assessment of Osteoporotic Fracture Risk

ObjectiveTo compare Fracture Risk Assessment Tool (FRAX) calculations with and without bone mineral density (BMD) in predicting the 10-year probability of hip and major osteoporotic fractures (MOF).MethodsA cross-sectional review of patients requiring screening for osteoporosis as part of their routine medical care was conducted. Postmenopausal women and men over 50 years of age who were never diagnosed with osteoporosis or treated with U.S. Food and Drug Administration-approved agents for osteoporosis were included. Height, weight, FRAX questionnaire, femoral neck BMD, and T-score data were obtained. FRAX scores with BMD (FRAX/BMD) and without BMD (FRAX) were calculated. Subjects were separated on the basis of identical and different treatment recommendations. Fracture risk factors were compared between groups using simple Student’s t test analysis of numerical variables and Fisher’s exact test analysis of binary variables.ResultsOf 151 total subjects, 127 (84%) had identical fracture risk predictions with or without BMD included in the FRAX calculation. Thirty subjects met treatment criteria and 97 did not, but the FRAX prediction was the same with risk factors alone or with risk factors plus BMD. Age was the only risk factor that was significantly different between those with identical and different predictions (median age, 64.42 and 76.25 years, respectively; P<.001).ConclusionIn most cases, FRAX alone provides the same prediction as FRAX with BMD. Younger age is more indicative of an identical prediction. (Endocr Pract. 2013;19:780-784)     

Beyond Dxa: Advances in Clinical Applications of New Bone Imaging Technology

Dual-energy X-ray absorptiometry (DXA) is generally a very useful tool for assessing bone mineral density (BMD) and fracture risk. However, observational studies have shown that in certain instances, BMD as measured by DXA systematically over- or underestimates fracture risk. We herein describe the clinical conundrums encountered when assessing fracture risk by DXA in patients with primary hyperparathyroidism or type 2 diabetes and those of Chinese ethnicity. Furthermore, we discuss how advanced imaging technology that examines skeletal microarchitecture is furthering our understanding of fracture risk in these clinical situations.Abbreviations:BMD = bone mineral densityBMI = body mass indexBMS = bone material strengthBMT = bone microindentation testing3D = 3-dimensionalDM2 = type 2 diabetes mellitusDXA = dual-energy X-ray absorptiometryμFEA = microstructural finite element analysisFRAX = fracture risk assessment toolHRpQCT = high-resolution peripheral quantitative computed tomographyID = indentation distanceIDI = indentation distance increaseITS = individual trabecular segmentationPHPT = primary hyperparathyroidismPTH = parathyroid hormoneTBS = trabecular bone score     

The Associations Between Hypovitaminosis D,Higher Pth Levels With Bone Mineral Densities,And Risk Of The 10-Year Probability Of Major Osteoporotic Fractures In Chinese Patients With T2Dm

Objective: In the current study, we investigated the vitamin D status, and its relationships with parathyroid hormone (PTH) levels, bone mineral density (BMD), and the 10-year probability of fractures in Chinese patients with type 2 diabetes mellitus (T2DM).Methods: This was a cross-sectional study of 785 patients. BMDs at the lumbar spine (L2-4), femoral neck (FN), and total hip (TH) were measured by dual-energy X-ray absorptiometry (DXA). Serum levels of 25-hydroxyvitamin D (25(OH)D) and intact PTH were also quantified. The 10-year probability of fracture risk (major osteoporotic fracture &lsqb;MOF] and hip fracture &lsqb;HF]) was assessed using the fracture risk assessment tool (FRAX).Results: The prevalence of vitamin D deficiency was 82.3%, and the mean 25(OH)D level was 36.9 ± 15.2 nmol/L. The adequate group had higher BMDs at the FN and TH and lower MOF risk than the inadequate groups. Lower 25(OH)D was associated with higher PTH (r = -0.126, P<.001). PTH was negatively correlated with BMDs at 3 sites and positively correlated with MOF and HF, but this relationship disappeared in the adequate subgroup. Multivariate stepwise regression analysis revealed that PTH was the determinant of MOF (standard β = 0.073, P = .010) and HF (standard β = 0.094, P = .004).Conclusion: Our results identified a significantly high rate of vitamin D deficiency among Chinese patients with T2DM. PTH is an important risk factor responsible for the higher 10-year probability of osteoporotic fractures in diabetic patients, especially in those with lower vitamin D levels.Abbreviations: AKP = alkaline phosphatase; ALB = serum albumin; BMD = bone mineral density; BMI = body mass index; Ca = calcium; CKD = chronic kidney disease; Cr = creatinine; FN = femoral neck; FRAX = fracture risk assessment tool; HbA1c = glycated hemoglobin A1c; HF = hip fracture; L2-4 = lumbar spine; MOF = major osteoporotic fracture; 25(OH)D = 25-hydroxyvitamin D; P = phosphorus; PTH = parathyroid hormone; T2DM = type 2 diabetes mellitus; TH = total hip; UA = uric acid     

Improving Osteoporosis Management in Primary Care: An Audit of the Impact of a Community Based Fracture Liaison Nurse

Background

Osteoporosis and associated fragility fractures are a major health problem; they are more common in women over 50 years old. Fracture liaison nurses have been widely used in secondary care to promote the recognition of fragility fractures and to promote the use of bone-sparing medication to reduce the risk of recurrent facture.

Objective

Audit the impact of a primary care based fracture liaison nurse on the detection of fragility fractures in people with osteoporosis and their treatment with a bone-sparing medication.

Method

This audit took place in 12 GP practices using ‘before and after’ cross-sectional extractions of anonymised routine data. We report, for females 50–74 years and ≥75 years old, socio-economic deprivation index, the prevalence of osteoporosis, recording of fragility fractures, dual-energy X-ray absorptiometry (DXA), smoking, and body-mass index (BMI) and use of appropriate bone-sparing medication. We used Altman’s test of independent proportions to compare before and after data.

Results

Recording of the diagnosis of osteoporosis increased from 1.5% to 1.7% (p = 0.059); the rate of DXA scans fell (1.8% to 1.4%; p = 0.002); recording of fractures and fragility fractures more than doubled (0.8% to 2.0%; p<0.001 and 0.5% to 1.5%; p<0.001, respectively) with approximate doubling of the recording of smoking, and BMI (p<0.001 level). Fragility fracture recording rose from 8.8% to 15% in females aged 50 to 74, and from 0.8% to 2.3% in people aged ≥75years old (p<0.001). There appeared to be inequity in the service, people who were least deprived were more likely to receive DXA scans and the more deprived to be prescribed bone sparing agents.

Conclusion

A fracture liaison nurse in primary care has been associated with a period of improved management. Liaison nurses based in different parts of the health system should be tested in a prospective trial.     

Bone Mineral Density of the 1/3 Radius Refines Osteoporosis Diagnosis,Correlates With Prevalent Fractures,and Enhances Fracture Risk Estimates

ObjectiveTo investigate the added value of 1/3 radius (1/3R) for the diagnosis of osteoporosis by spine and hip sites and its correlation with prevalent fractures and predicted fracture risk.MethodsFracture Risk Assessment Tool (FRAX) scores for hip and major osteoporotic fractures (MOF) with/without trabecular bone score were considered proxy for fracture risk. The contribution of 1/3R to risk prediction was depicted via linear regression models with FRAX score as the dependent variable—first only with central and then with radius T-score as an additional covariate. Significance of change in the explained variance was compared by F-test.ResultsThe study included 1453 patients, 86% women, aged 66 ± 10 years. A total of 32% (n = 471) were osteoporotic by spine/hip and 8% (n = 115) by radius only, constituting a 24.4% increase in the number of subjects defined as osteoporotic (n = 586, 40%). Prior fracture prevalence was similar among patients with osteoporosis by spine/hip (17.4%) and radius only (19.1%) (P = .77).FRAX prediction by a regression model using spine/hip T-score yielded explained variance of 51.8% and 49.9% for MOF and 39.8% and 36.4% for hip (with/without trabecular bone score adjustment, respectively). The contribution of 1/3R was statistically significant (P < .001) and slightly increased the explained variance to 52.3% and 50.4% for MOF and 40.9% and 37.4% for hip, respectively.ConclusionReclassification of BMD results according to radius measurements results in higher diagnostic output. Prior fractures were equally prevalent among patients with radius-only and classic-site osteoporosis. FRAX tool performance slightly improved by incorporating radius BMD. Whether this approach may lead to a better fracture prediction warrants further prospective evaluation.     

Comparison Of The Long-Term Effects Of Liraglutide And Glimepiride Monotherapy On Bone Mineral Density In Patients With Type 2 Diabetes

Objective: Patients with type 2 diabetes have an increased risk of fragility fractures; the cause is unclear but is likely multifactorial. Some diabetes treatments induce bone loss, accentuating underlying skeletal fragility and increasing fracture risk. This subgroup analysis aimed to compare long-term effects of liraglutide and glimepiride on bone mineral density (BMD) in patients with type 2 diabetes.Methods: LEAD-3, a 52-week, double-blind, activecontrol, phase III, multicenter trial, investigated the efficacy of liraglutide (1.2 and 1.8 mg/day) versus glimepiride monotherapy in type 2 diabetes. A 52-week, open-label extension followed, in which participants remained on randomized therapy. A subgroup of participants underwent BMD measurement by dual-energy X-ray absorptiometry at baseline, 52, and 104 weeks. The main outcome measure was change from baseline in total body BMD at 52 and 104 weeks, assessed by analysis of covariance.Results: A total of 746 patients with type 2 diabetes aged 19 to 79 years were randomized into the main trial. Of these, 61 patients (20 assigned to liraglutide 1.8 mg/day, 23 to liraglutide 1.2 mg/day, 18 to glimepiride 8 mg/day) had BMD measurements. Baseline age, body mass index, diabetes duration, glycated hemoglobin, and total BMD were similar across treatment groups. There was no apparent difference in mean total BMD change from baseline in patients receiving liraglutide 1.8 or 1.2 mg/day or glimepiride 8 mg/day at 52 or 104 weeks.Conclusion: In this small subgroup analysis, liraglutide monotherapy did not negatively affect total BMD in a 2-year prospective study, suggesting it may not exacerbate the consequences of bone fragility.Abbreviations:BMD = bone mineral densityBMI = body mass indexDPP-4 = dipeptidyl peptidase-4DXA = dual-energy X-ray absorptiometryGLP-1RA = glucagon-like peptide 1 receptor agonistLEAD = Liraglutide Effect and Action in DiabetesTZD = thiazolidinedione     

Opportunistic Evaluation of Bone Mineral Density By Pet-Ct in Hodgkin Lymphoma Patients

Objective: Bone density loss and increased risk for osteoporosis are of concern in Hodgkin lymphoma (HL) patients. Routinely performed positron emission tomography–computed tomography (PET-CT) scans could be informative in assessing bone mineral density (BMD).Methods: This retrospective study included 80 adults with newly diagnosed HL treated with standard first-line chemotherapy regimens. PET-CT scans performed at diagnosis (PET-CT₁), at the end of chemotherapy (PET-CT₂), and at follow-up after remission (PET-CT₃) were used to assess BMD changes by measuring lumbar vertebrae CT attenuation. A CT attenuation threshold of 160 Hounsfield units was used to define abnormal BMD.Results: Following chemotherapy, comparison of PET-CT₂ with PET-CT₁ revealed a mean (standard deviation) 14.2% (10.4%) BMD reduction (P<.001). On PET-CT₃ performed at 14.6 (3.25) months after the last course of chemotherapy, a slight improvement (4.6% &lsqb;10.4%]) in comparison to PET-CT₂ was noted. Twelve patients (15%) converted from normal baseline BMD on PET-CT₁ to abnormal BMD after chemotherapy on PET-CT₂. Age, baseline BMD, and steroid cumulative dose were associated with BMD decline and risk for abnormal BMD after chemotherapy. No clinical fractures were reported, and only one rib fracture was incidentally captured (1.25%).Conclusion: HL patients treated with common first-line chemotherapies demonstrate a significant decline in bone density on routine PET-CT scans. Opportunistic use of PET-CT scan has the potential to detect HL patients at high risk for developing osteoporosis and to guide clinicians regarding monitoring and intervention.Abbreviations: BMD = bone mineral density; CT = computed tomography; DXA = dual-energy X-ray absorptiometry; HL = Hodgkin lymphoma; HU = Hounsfield units; L = lumbarvertebra; PET-CT = positron emission tomography-computed tomography; T = thoracic vertebra     

Prevalent Morphometric Vertebral Fractures in Professional Male Rugby Players

There is an ongoing concern about the risk of injury to the spine in professional rugby players. The objective of this study was to investigate the prevalence of vertebral fracture using vertebral fracture assessment (VFA) dual energy X-ray absorptiometry (DXA) imaging in professional male rugby players. Ninety five professional rugby league (n = 52) and union (n = 43) players (n = 95; age 25.9 (SD 4.3) years; BMI: 29.5 (SD 2.9) kg.m²) participated in the research. Each participant received one VFA, and one total body and lumbar spine DXA scan (GE Lunar iDXA). One hundred and twenty vertebral fractures were identified in over half of the sample by VFA. Seventy four were graded mild (grade 1), 40 moderate (grade 2) and 6 severe (grade 3). Multiple vertebral fractures (≥2) were found in 37 players (39%). There were no differences in prevalence between codes, or between forwards and backs (both 1.2 v 1.4; p>0.05). The most common sites of fracture were T8 (n = 23), T9 (n = 18) and T10 (n = 21). The mean (SD) lumbar spine bone mineral density Z-score was 2.7 (1.3) indicating high player bone mass in comparison with age- and sex-matched norms. We observed a high number of vertebral fractures using DXA VFA in professional rugby players of both codes. The incidence, aetiology and consequences of vertebral fractures in professional rugby players are unclear, and warrant timely, prospective investigation.     

Transient Osteoporosis: Clinical Spectrum in Adults and Associated Risk Factors

Objective: We aimed to describe the natural history of the rare clinical syndrome of transient osteoporosis (TO) and ascertain potential risk factors.Methods: Retrospective cohort study of adults with TO at Mayo Clinic, Rochester, Minnesota, over 15 years. Adults with acute-onset joint pain worsened by weight bearing and bone marrow edema on magnetic resonance imaging were included; exclusion criteria were trauma, tumors, rheumatic diseases, avascular necrosis, infection, and hyperesthesia.Results: Thirty-three patients with TO were identified: 20 males, median age at diagnosis 47 years, and median body mass index 28 kg/m². Median time to diagnosis was 2 months, and time to symptom resolution was 4 months. All cases involved the lower extremity, with the majority affecting the hip. Most patients (79%) had at least one possible identified risk factor. The most frequent risk factor was low bone mineral density (BMD) in 13 patients (39% of cohort). Of the 16 patients with BMD measure, 8 had low BMD at a site other than TO. The next most frequent risk factors were sudden limb overuse and more than one episode of TO, observed in 30%, followed by a disorder of bone and mineral metabolism in 27%.Conclusion: TO affects middle-age men more than women, primarily involves weight-bearing joints, and usually resolves with conservative management. Its etiology remains unclear; however, the common presence of risk factors, abnormalities in bone and mineral laboratories, and decrease in BMD suggest that systemic factors may be important in its development.Abbreviations: AVN = avascular necrosis; BMD = bone mineral density; DXA = dual-energy X-ray absorptiometry; MRI = magnetic resonance imaging; TO = transient osteoporosis     

Osteoporosis,the risk of vertebral fracture,and periodontal disease in an elderly group in Mexico City

doi: 10.1111/j.1741‐2358.2009.00342.x
Osteoporosis, the risk of vertebral fracture, and periodontal disease in an elderly group in Mexico City Objectives: The aims of this study were to identify the possible association of osteoporosis, fracture risk and periodontitis, and consider the role of pharmacological treatment of osteoporosis and the periodontal condition. Methods: Patients aged 60 and older from the Mexican National Medical Science and Nutrition Institute Salvador Zubirán participated in the study. DXA was used to assess osteoporosis and risk of vertebral fracture. A modified version of the extent and severity index (ESI) was applied to evaluate periodontitis (cut‐off point for attachment loss ≥ 4 mm) and all teeth were examined. Results: One hundred and sixty‐six patients were examined, 88.6% were females, 47.0% had osteoporosis and 38.6% showed a high risk of fracture. The modified ESI was 5.13 mm (SD 1.4), 57.8% (SD 29.7). The model for periodontitis severity showed an association with oral hygiene (OR = 1.85) and use of osteoporosis medication (OR = 0.43). The model for the extent of periodontitis identified an association with smoking (OR = 2.37), osteoporosis (OR = 1.82) and osteoporosis medication (OR = 0.36). The model for tooth loss detected an association with fracture risk (OR = 3.02) and osteoporosis medication (OR = 0.33). Conclusion: Periodontitis extent was associated with osteoporosis, and tooth loss with fracture risk.     

PKP治疗骨质疏松性椎体压缩骨折的预后评价及继发危险因素分析

目的:分析椎弓根入路行椎体后凸成形术(PKP)治疗骨质疏松性椎体压缩骨折的预后评价及继发危险因素分析。方法:选择2016年2月-2018年2月我院收治的骨质疏松性椎体压缩骨折患者85例纳入本次研究,采用随机数表法分为观察组(n=43)和对照组(n=42)。对照组使用经皮椎体成形术进行治疗,观察组采用PKP进行治疗。比较两组患者手术情况、术后情况、椎体前缘高度丢失率、Cobb角、继发性骨折发生情况及分析骨质疏松性椎体压缩骨折患者术后继发骨折的危险因素。结果:观察组手术时间、透视次数、骨水泥注入量、术中出血量均显著低于对照组,差异显著(P0.05);观察组疼痛缓解时间、下地时间及住院时间均显著低于对照组,差异显著(P0.05);治疗前,两组椎体前缘高度丢失率、Cobb角比较,无显著差异;治疗后,两组患者的椎体高度丢失率明显下降,但两组术后7 d、术后6月两组椎体前缘高度丢失率、Cobb角比较无显著差异;观察组术后12月椎体前缘高度丢失率、Cobb角低于对照组,差异显著(P0.05);所有患者均随访12月,其中22例(25.88%)发生继发性椎体骨折,进行单因素分析,结果发现,两组患者性别、骨折部位、局部矢状面后凸角度、骨水泥量、椎体高度恢复、术后抗骨质疏松治疗差异无统计学意义(P0.05);骨质疏松原因、骨水泥椎间隙渗漏、术后支具佩戴、原发骨折类型与骨质疏松性椎体压缩骨折患者术后发生继发骨折相关(P0.05)。多因素Logistic分析显示,骨质疏松原因、骨水泥椎间隙渗漏、术后支具佩戴、原发骨折类型均是骨质疏松性椎体压缩骨折患者术后发生继发骨折的独立危险因素(P0.05)。结论:在骨质疏松性椎体压缩骨折患者中应用PKP可有效改善手术情况,随着时间的延长,PKP更有利于维持患者椎体高度;骨质疏松原因、骨水泥椎间隙渗漏、术后支具佩戴、原发骨折类型是骨质疏松性椎体压缩骨折患者术后发生继发骨折的危险因素,临床上对于具有危险因素的患者引起重视,并采取干预措施。     

Virtual Orthopedic-Rehabilitation-Metabolic Collaboration for Treating Osteoporotic HIP Fractures

Objective: To evaluate the effectiveness of a virtual, closed-loop protocol that treated hip fracture patients without formal clinic visits.Methods: In this prospective cohort study, an intervention group of 85 hip fracture patients (33.6%) with vitamin D levels ≥65 nmol/L who received recommendations for osteoporosis treatment, was compared to a nonintervention group of 168 (66.4%), with vitamin D <65 nmol/L. Treatment included vitamin D loading in orthopedic and rehabilitation departments for patients from both groups, and virtual, osteoporosis treatment recommendations by Metabolic Clinic physicians to patients from the intervention group upon achieving a vitamin D level ≥65 nmol/L. Recommendations were given without requiring clinic visits. Osteoporosis drug recommendations were relayed to primary care physicians. The primary endpoint was patients receiving osteoporosis drugs within 12-months post-surgery. Secondary endpoints were patients issued drugs within 3- and 6-months post-surgery, and 1-year post-fracture mortality rates.Results: Among 253 hip fracture patients (81.3 ± 10.7 years-of-age, 68.8% women), the postintervention osteoporosis medication issue rate was higher than in the nonintervention group (48.2% versus 22.0%, respectively; P<.001). More intervention group patients received drugs 3 months (18.8% versus 2.9%; P<.001) and 6 months after surgery (40% versus 5.9%; P<.001). One-year mortality was lower among patients who received any osteoporosis medications (either through our intervention or from community physicians) than among untreated patients (5.1% versus 26.3%; P<.001).Conclusion: Virtual orthopedic-rehabilitation-metabolic collaboration increased osteoporosis treatment rates post-hip fracture. Yet, treatment rates remained <50%. Additional research is required to increase treatment rates further, such as providing drug therapy shortly after surgery, perhaps during rehabilitation, or lowering the vita-min D threshold.Abbreviations: CHS = Clalit Health Services; FLS = Fracture liaison service; HMO = Health Maintenance Organization; MMC = Meir Medical Center; PCP = primary care physician     

Osteoporosis Treatment After Osteoporotic Fractures: Data From a Single Medical Center

ObjectiveMost patients do not receive osteoporosis treatment after osteoporotic fracture. This study reviewed osteoporosis treatment after osteoporotic fractures in a center without a Fracture Liaison Service.MethodsWe identified all patients with hip, vertebral, humeral or radial fractures, evaluated in Meir Medical Center, in 2017. The exclusion criteria were not a Clalit Health Services member, high-energy fracture or 30-day postoperative mortality. The primary endpoint was osteoporosis drugs issued within 12 months of fracture. Secondary endpoints included bone densitometry and 1-year mortality.ResultsFive-hundred-eighty-two patients (average age 78.6 ± 11.1 years, 75.8% women) were included. There were 321 (55.5%) hip, 84 (14.1%) humeral, 33 (5.6%) vertebral, and 144 (24.7%) radial fractures. Osteoporosis drugs were issued to 26.5% of the patients; those with humeral fractures received the least (21.4%) and vertebral, the most (30.3%; P = .51). Bone densitometry was performed in 23.2% of patients. One-year mortality after hip fracture was 12.1%, followed by humeral (3.6%; P < .05). Logistic regression showed that previous treatment (odds ratio [OR] = 7.4; 95% confidence interval [CI] 3.6–15.2), bone densitometry (OR = 4.4; 95% CI 2.6–7.4) and endocrinology visit (OR = 2.6; 95% CI, 1.4–4.6) were the most important factors associated with treatment.ConclusionFewer than one third of patients received pharmacotherapy within 1 year after fracture. Because pharmacotherapy reduces future fractures and mortality, we recommend that medical staff who care for patients with fracture adopt practical and effective strategies to increase treatment rates among patients with osteoporotic fractures.     

Osteoporosis in ankylosing spondylitis - prevalence, risk factors and methods of assessment

Introduction

Osteoporosis can be a complication of ankylosing spondylitis (AS), but diagnosing spinal osteoporosis can be difficult since pathologic new bone formation interferes with the assessment of the bone mineral density (BMD). The aims of the current study were to investigate prevalence and risk factors for reduced BMD in a Swedish cohort of AS patients, and to examine how progressive ankylosis influences BMD with the use of dual-energy x-ray absorptiometry (DXA) of the lumbar spine in different projections.

Methods

Methods of assessment were questionnaires, back mobility tests, blood samples, lateral spine radiographs for syndesmophyte grading (mSASSS), DXA of the hip, radius and lumbar spine in anteroposterior (AP) and lateral projections with estimation of volumetric BMD (vBMD).

Results

AS patients (modified New York criteria), 87 women and 117 men, mean age 50 ± 13 years and disease duration 15 ± 11 years were included. According to World Health Organization (WHO) criteria 21% osteoporosis and 44% osteopenia was diagnosed in patients > = 50 years. Under age 50 BMD below expected range for age was found in 5%. Interestingly lateral lumbar DXA showed significantly lower BMD and revealed significantly more cases with osteoporosis as compared with AP DXA. Lumbar vBMD was not different between sexes, but women had significantly more lumbar osteoporosis measured with AP DXA (P < 0.001). Men had significantly higher mSASSS (P < 0.001). Low BMD was associated with high age, disease duration, mSASSS, Bath Ankylosing Spondylitis Metrology Index (BASMI), inflammatory parameters and low body mass index (BMI). Increasing mSASSS correlated significantly with decreasing lateral and volumetric lumbar BMD, while AP lumbar BMD showed tendency to increase.

Conclusions

Osteoporosis and osteopenia is common in AS and associated with high disease burden. Lateral and volumetric lumbar DXA are more sensitive than AP DXA in detecting osteoporosis and are less affected by syndesmophyte formation.     

Exposure to Famine in Early Life and the Risk of Osteoporosis in Adulthood: a Prospective Study

Objective: To assess the association between famine exposure in early life and osteoporosis in adulthood.Methods: A total of 2,292 participants born between 1955 and 1965 in Fujian Province were selected; after 3 years, 1,378 participants attended a follow-up research visit. Calcaneus bone mineral density and bone quality were measured by quantitative ultrasound. The T-score was used to assess bone mineral density, and the parameters quantitative ultrasound index (QUI), speed of sound (SOS), and broadband ultrasonic attenuation (BUA) were used to assess bone quality. A T-score threshold of -1.8 was defined as osteoporosis, and a possible vertebral fracture was considered as a prospective height loss of 0.8 inches or more.Results: Compared with the nonexposed cohort, risks of osteoporosis for fetal-, early childhood, and mid-childhood famine-exposed cohorts in postmenopausal women were adjusted odds ratio (OR), 3.741 (95% confidence interval [CI], 1.233, 11.44) versus OR 2.894 (95% CI, 0.997, 8.571) versus OR 4.699 (95% CI, 1.622, 13.612) by logistic regression but not significant in men. Moreover, the fetal-exposed cohort had a weak negative relation with QUI (β, -5.07 [-10.226, 0.127]) and BUA (β, -4.321 [-0.88, 0.238]). The early- and mid-childhood–exposed cohorts had significantly lower QUI (β, -7.085 [-11.799, -2.372] versus β, -10.845 [-15.68, -6.01]) and BUA (β, -6.381 [-10.515, -2.246] versus β, -8.573 [-12.815, -4.331]) than the nonexposed cohort by linear regression. None of the famine-exposed cohorts had a significant relationship with SOS.Conclusion: Famine exposure during early life is associated with higher risk of osteoporosis in adulthood, which is most obvious in postmenopausal women. Furthermore, famine exposure in early life has adverse effects on bone quality.Abbreviations: BMD = bone mineral density; BUA = broadband ultrasonic attenuation; CI = confidence interval; OR = odds ratio; QUI = quantitative ultrasound index; QUS = quantitative ultrasound; SOS = speed of sound     

Orthopedic-Metabolic Collaborative Management for Osteoporotic Hip Fracture

Objective: Osteoporotic hip fractures are associated with increased morbidity, mortality, and secondary fractures. Although osteoporosis treatment can reduce future fracture risk, patients often do not receive it. We report results of a coordinator-less fracture liaison service in Israel addressing hip fracture patients. The primary endpoint was attending the Metabolic Clinic. Secondary endpoints included vitamin D measurement, calcium and vitamin D recommendations, initiation of osteoporosis treatment, and mortality 1-year post-fracture.Methods: This prospective study included 219 hip fracture patients who were compared with historical controls. Data on hospitalized patients were collected before and after implementation of a structured protocol for hip fracture patients, led by a multidisciplinary team, without a coordinator.Results: The study included 219 and 218 patients ≥60 years old who were operated on in 2013 and 2012, respectively. Metabolic Clinic visits increased from 6.4 to 40.2% after the intervention (P<.001). Among 14 patients who attended the Clinic in 2012, 85.7% began osteoporosis therapy; among 88 who attended in 2013, 45.5% were treated at the first visit. Vitamin D measurements and calcium and vitamin D supplementation increased postintervention (0.5–80.1%, P<.001; 30.8–84.7%, P<.001, respectively). Patients receiving osteoporosis medications had lower mortality rates than untreated patients (4.3% vs. 21.8%).Conclusion: An Orthopedic-Metabolic team implemented by existing staff without a coordinator can improve osteoporosis care for hip fracture patients. Yet, gaps remain as only 40% had Metabolic Clinic follow-up postintervention, and of these, only half received specific treatment recommendations. Hospitals are encouraged to adopt secondary fracture prevention protocols and continuously improve them to close the gaps between current management and appropriate metabolic assessment and treatment.Abbreviations: CHS = Clalit Health Services; CI = confidence interval; FLS = fracture liaison service; HMO = health maintenance organization; OR = odds ratio     

Metformin-Sustained Weight Loss and Reduced Android Fat Tissue At 12 Months In Empowir (Enhance The Metabolic Profile Of Women With Insulin Resistance): A Double Blind,Placebo-Controlled,Randomized Trial of Normoglycemic Women with Midlife Weight Gain

Objective: To assess 12-month body weight (BW) and body composition changes in normoglycemic women with midlife weight gain, after dietary and pharmacologic interventions targeting hyperinsulinemia.Methods: EMPOWIR (Enhance the Metabolic Profile of Women With Insulin Resistance; NCT00618072) was a double-blind, placebo-controlled, 12-month trial of women with >20-pound weight gain, normal glucose tolerance test, and increased area-under-the-curve insulin. Subjects (mean ± SD, 46.7 ± 6.5 years of age; body mass index, 30.8 ± 2.8 kg/m²; 50% white) attended 4 nutrition workshops to introduce a novel carbohydrate-modified diet (CMD) and were then randomized to one of three arms for 6 months (phase 1): CMD alone (D), or in combination with metformin (M), or metformin + rosiglitazone (MR), with rerandomization of the D group to one of the active treatment arms (phase 2, months 7 through 12). Repeated measure analysis of variance was used to assess BW at baseline, 6 months, and 12 months in 32 subjects with 12-month data; paired t tests compared baseline and 12-month dual-energy X-ray absorptiometry–derived body composition.Results: Mean (±SD) BW decreased significantly at 12 months in the M arm: 85.1 ± 8.5 kg to 79.8 ± 9.0 kg (P = .0003), with 54% of variance in weight over time explained by M treatment. Mean (±SD) percent android fat decreased significantly in the M and D arms: 53.5 ± 4.8% to 49.3 ± 7.6% (P = .010) and 52.9 ± 6.2% to 48.1 ± 8.7% (P = .021).Conclusion: In combination with a novel carbohydrate modified diet, metformin enhanced 12-month weight loss and improved body composition in ethnically diverse normoglycemic, hyperinsulinemic women with midlife weight gain. These findings suggest that EMPOWIR's easily implemented dietary interventions, alone and in combination with pharmacotherapies that target hyperinsulinemia, merit additional investigation in larger, long-term studies.Abbreviations:ANOVA = analysis of varianceBC = body compositionBW = body weightCMD = carbohydrate-modified dietD = diet alone groupDXA = dual-energy X-ray absorptiometryEMPOWIR = Enhance the Metabolic Profile of Women With Insulin ResistanceM = metformin groupMR = metformin + rosiglitazone group