Interim report and recommendations of the World Health Organization Task-Force for Osteoporosis

Association between Osteoporosis and Cognitive Impairment during the Acute and Recovery Phases of Ischemic Stroke

Background and objectives: Little is known about the effect of osteoporosis on cognitive function in the acute and recovery phases of stroke. Early bone mineral density assessments during acute stroke may be a useful marker of cognitive function. We evaluated the effect of osteoporosis on cognitive function at the early and recovery phase of ischemic stroke in patients aged >50 years. Materials and Methods: We retrospectively examined consecutive patients with acute stroke hospitalized between 2016 and 2018. Osteoporosis was defined as a T-score <–2.5 for the femoral neck or lumbar spine bone mineral density. The primary outcome was cognitive impairment measured by the Korean Mini-Mental State Examination in the acute phase and recovery phase of ischemic stroke. Results: Of the 260 included subjects (107 men and 153 women), 70 (26.9%) had osteoporosis. Cognitive impairment was more severe in the osteoporosis group than in the non-osteoporosis group (30.5% versus 47.1%, p = 0.001). After the recovery phase of stroke, the proportion of patients with cognitive impairment remained higher in the osteoporosis group. The multivariate analysis revealed a correlation between a low femoral neck bone mineral density and severe cognitive impairment in the acute and recovery phases of stroke (adjusted odds ratio (OR) 4.09, 95% confidence interval (CI) 1.11–15.14 in the acute phase, and adjusted OR 11.17, 95% CI 1.12–110.98 in the recovery phase). Conclusions: Low bone mineral density is associated with poor cognitive function in the acute and recovery phases of stroke.

Osteopenia and osteoporosis among treatment-experienced people living with HIV

Introduction

Life expectancy of people living with human immunodeficiency (PLHIV) has increased mainly due to the accessibility and effectiveness of antiretroviral therapy (ART). However, adverse effects from long-term use of antiretrovirals, and the physiological changes associated with aging, may compromise the quality of life of PLHIV, in addition to causing new demands on the healthcare system.

Objectives

Estimate the frequency of osteoporosis and osteopenia in patients on prolonged ART and to verify their associated factors.

Methods

A cross-sectional study was conducted in Belo Horizonte, Minas Gerais, Brazil, from August 2017 to June 2018, in a sample of PLHIV (age ≥ 18 years) who started ART between 2001 and 2005. Data were collected through face-to-face interviews, physical evaluation, laboratory tests, and Dual-Energy X-Ray Absorptiometry Screening (DEXA). The outcome of interest was presence of bone alteration, defined as presence of osteopenia or osteoporosis in DEXA. The association between the explanatory variables and the event was assessed through odds ratio (OR) estimate, with 95% confidence interval (CI). Multiple logistic regression was performed to evaluate factors independently associated with bone alteration.

Results

Among 92 participants, 47.8% presented bone alteration (19.6% osteoporosis and 28.2% osteopenia). The variables that remained in the final logistic regression model were age ≥ 50 years (OR: 12.53; 95% CI: 4.37–35.90) and current alcohol use (OR: 2.63; 95% CI: 0.94–7.37).

Conclusions

This study showed a high frequency of bone changes, especially in PLHIV older than 50 years. This information is useful to stimulate the screening and timely intervention of this comorbidity of PLHIV on prolonged use of ART in order to prevent or minimize complications and new demands on the healthcare system.

Increased fracture rate in children and adolescents with Marfan syndrome

Marfan syndrome (MFS) is an autosomal genetic disorder of connective tissue, due to alterated fibrillin-1. The aim of our study was to verify the rate of fractures in children with MFS in correlation to bone mineral density and compare the prevalence to the general population in the same latitude. We enrolled 80 patients (37 girls and 43 boys) with the diagnosis of Marfan syndrome, median age 10 y (3 to 17 years). Fracture occurrence was inferred from medical records of patients with MFS. Bone mineral density (BMD) was measured at lumbar spine, femoral neck and total femur by dual-energy x-ray absorptiometry. BMD values were expressed as z-scores, and adjusted for height using height-for-age z-scores. Bone turnover markers and vitamin D were measured. We assessed incidence of fracture in general pediatric population of our geographic area (45°N latitude). A total of 24 fractures were recorded in 21 patients (15 boys and 6 girls), involving both short and long bones, due to mild or moderate trauma. An incidence estimate has been calculated for each year, and an average incidence of 29.2/1000 MFS patients was obtained, markedly higher (P=0.034) than the incidence of fracture calculated in the same geographical area in pediatric patients (15.8/1000). We did not detect differences in anthropometric measurements, BMD values and biochemical indices between patients who fractured and patients who did not. Similarly, no differences were found between patients on losartan therapy and patients not in treatment for the same variables. In conclusion, the incidence of fractures was higher in patients with MFS compared to general population of the same age and latitude. The management of MFS must account bone status health and start strategies of fracture prevention.

Objectively-measured sedentary time, habitual physical activity and bone strength in adults aged 62 years: the Newcastle Thousand Families Study

BACKGROUND

The influence of sedentary time and habitual physical activity on the bone health of middle aged adults is not well known.

METHODS

Bone mineral density (BMD) and hip bone geometry were evaluated in 214 men (n = 92) and women (n = 112) aged 62.1 ± 0.5 years from the Newcastle Thousand Families Study birth cohort. Accelerometry was used to measure physical activity (PA) and sedentary time over 4 days. Regression models were adjusted for clinical risk factor covariates.

RESULTS

Men were more sedentary than women (P < 0.05), and sedentary time was negatively associated with spine BMD in men, with 84 minutes more sedentary time corresponding to 0.268 g.cm-2 lower BMD (β = -0.268; P = 0.017). In men, light PA and steps/day were positively associated with bone geometry and BMD. Steps/day was positively associated with bone geometry and femur BMD in women, with a positive difference of 1415 steps/day corresponding to 0.232 g.cm-2 greater BMD (β = 0.232, P = 0.015).

CONCLUSIONS

Sedentary time was unfavourably associated with bone strength in men born in North East England at age 62 years. Higher volumes of light PA, and meeting the public health daily step recommendations (10 000 steps/day) was positively associated with bone health in both sexes.

A comprehensive study on feature types for osteoporosis classification in dental panoramic radiographs

BACKGROUND AND OBJECTIVE

Osteoporosis is a disease characterized by a decrease in bone density. It is often associated with fractures and severe pain. Previous studies have shown a high correlation between the density of the bone in the hip and in the mandibular bone in the jaw. This suggests that dental radiographs might be useful for detecting osteoporosis. Use of dental radiographs for this purpose would simplify early detection of osteoporosis. However, dental radiographs are not normally examined by radiologists. This paper explores the use of 13 different feature extractors for detection of reduced bone density in dental radiographs.

METHODS

The computed feature vectors are then processed with a Self-Organizing Map and Learning Vector Quantization as well as Support Vector Machines to produce a set of 26 predictive models.

RESULTS

The results show that the models based on Self-Organizing Map and Learning Vector Quantization using Gabor Filter, Edge Orientation Histogram, Haar Wavelet, and Steerable Filter feature extractors outperform the rest of the 22 models in detecting osteoporosis. The proposed Gabor-based algorithm achieved an accuracy of 92.6%, a sensitivity of 97.1%, and a specificity of 86.4%.

CONCLUSIONS

The oriented edges and textures in the upper and lower jaw regions are useful for distinguishing normal patients from patients with osteoporosis.

Bone Turnover Markers After Standard and Distal Roux-en-Y Gastric Bypass: Results from a Randomized Controlled Trial

BACKGROUND

Roux-en-Y gastric bypass is associated with increased risk of bone fractures. Malabsorptive procedures may be associated with secondary hyperparathyroidism and detrimental effects on bone health. We aimed to compare the effects of standard and distal gastric bypass on bone turnover markers 2 years after surgery.

METHODS

Patients with body mass index (BMI) 50-60 kg/m² (n = 113) were randomized to standard or distal gastric bypass, 105 patients (95%) completed 2-year follow-up. Serum C-terminal telopeptide of type I collagen (CTX-1), procollagen type I N-propeptide (PINP), and bone-derived alkaline phosphatase (BALP) was measured at baseline and up to 2 years after surgery. ANCOVA and linear mixed models were used to compare groups.

RESULTS

The levels of bone turnover markers increased significantly in both groups, with no statistically significant difference between groups. Two years after standard and distal gastric bypass mean (SD) CTX-1 were 0.81 (0.32) and 0.83 (0.31) μg/L (p = 0.38), mean PINP was 77.6 (23.2) and 77.7 (29.3) μg/L (p = 0.42), and BALP 47.9 (21.9) vs. 50.7 (19.6) μg/L (p = 0.38), respectively. Multiple linear regression analyses showed that PINP and BALP correlated positively (p = 0.01 and p < 0.001) with PTH, but only BALP was significantly higher in patients with secondary hyperparathyroidism (p = 0.001). Type of surgery, vitamin D serum concentrations, and 2-year BMI were all independently associated with PTH levels.

CONCLUSION

A comparable increase in bone turnover markers 2 years after standard and distal gastric bypass was observed. There was a higher prevalence of secondary hyperparathyroidism after distal gastric bypass, but this did not impact bone turnover markers.

TRIAL REGISTRATION

Clinical Trials.gov number NCT00821197.

Baicalin Ameliorates Dexamethasone-Induced Osteoporosis by Regulation of the RANK/RANKL/OPG Signaling Pathway

Background

Osteoporosis is a chronic bone metabolism disorder affecting millions of the world population. The RANKL/RANK/OPG signaling pathway has been confirmed to be the main regulator of osteoporosis. It is of great interest to identify appropriate therapeutic agents that can regulate the RANKL/RANK/OPG pathway. Baicalin (BA) is a well-known traditional Chinese medicine formula against various inflammatory diseases with a proven role of the RANKL/RANK/OPG pathway regulation. However, the potential effect of BA on osteoporosis and the mechanisms underlying this remain unclear. In the present study, we aimed to evaluate the efficacy of BA in the prevention of dexamethasone (DEX)-induced osteoporosis in zebrafish.

Methods

In this study, growth and development changes of zebrafish and calcein staining were assessed with a micrograph. The expression levels of RANKL and OPG and transcription factors in response to DEX induction and BA administration were evaluated by Western blotting and qRT-PCR. In addition, the intermolecular interactions of BA and RANKL were investigated by molecular docking.

Results

Results show that BA enhances the growth and development of dexamethasone (DEX)-induced osteoporosis in zebrafish larvae. Calcein staining and calcium and phosphorus determination revealed that BA ameliorates mineralization of DEX-induced osteoporosis zebrafish larvae. BA also regulates the expression of RANKL and OPG and hampers the changes in gene expression related to bone formation and resorption under the induction of DEX in zebrafish. It can be inferred by molecular docking that BA may interact directly with the extracellular domain of RANKL.

Conclusion

The findings, herein, reveal that BA ameliorates DEX-induced osteoporosis by regulation of the RANK/RANKL/OPG signaling pathway.

A new lever reduction technique for the surgical treatment of elderly patients with lumbar degenerative Spondylolisthesis

BACKGROUND

Proper reduction method for Lumbar degenerative spondylolisthesis (LDS) is still controversial. The aim of this study was to determine the safety and effectiveness of lever reduction combined with traditional elevating-pull reduction technique for the treatment of elderly patients with LDS.

METHODS

From May 2015 to December 2017, 142 elderly patients (≥65 years) diagnosed with LDS were enrolled in this study with a mean follow-up of 25.42 ± 8.31 months. All patients were operated using lever reduction combined with traditional elevating-pull reduction technique. Patient age, sex, body mass index, bone mineral density, preoperative comorbidities, surgical duration, blood loss, and surgical complications were collected form patient charts. Clinical data as visual analog scale (VAS), Oswestry Disability Index (ODI), and 36-Item Short Form Health Survey (SF-36) were collected preoperatively, 1 month postoperatively, and at the final follow-up. Radiographic evaluation included slip percentage, slip angle (SA), lumbar lordosis (LL), and fusion status.

RESULTS

The clinical parameters of VAS_back, VAS_leg, ODI, and SF-36 had significantly improved at both follow-ups after surgery. A significant improvement was indicated for slippage reduction at both follow-ups, showing no significant correction loss after surgery. SA significantly increased after surgery and was well maintained at the final follow-up. LL was not affected by the surgery. At the final follow-up, complete fusion was obtained in 121 patients (85.2%) and partial fusion in 21 (14.8%). Revision surgery was performed for one patient. Screw loosening was observed in 3 (2.11%) cases. No nerve root injury or adjacent segment disease was observed.

CONCLUSIONS

This new lever reduction combined with traditional elevating-pull reduction technique for the surgical treatment of elderly patients with LDS is both safe and effective. Satisfactory correction and fusion rates were achieved with acceptable correction loss and reduction-related complications.

Changes in bone quality after Roux-en-Y gastric bypass: A prospective cohort study in subjects with and without type 2 diabetes

BACKGROUND

Obesity and type 2 diabetes (T2D) are associated with an increased risk of skeletal fractures despite a normal areal bone mineral density (aBMD) and low bone turnover, possibly due to reduced bone material strength. Roux-en-Y gastric bypass (RYGB) enables a substantial and persistent weight loss and resolution of obesity related comorbidities such as T2D. However, the procedure induces a decrease in aBMD and increased bone turnover and fracture rate. To our knowledge, changes in bone material strength after RYGB have not been explored. This study aimed to evaluate changes in factors influencing bone quality; bone material strength, aBMD and bone turnover markers, in a population with morbid obesity undergoing RYGB and whether these changes differed in participants with and without T2D. We also sought to assess factors associated with bone material strength and bone mineral density in obese subjects before and after RYGB.

METHODS

We examined 34 participants before and one year after RYGB, of whom 13 had T2D. Bone material strength index (BMSi) was evaluated by impact microindentation, aBMD and body composition by Dual energy X-ray absorptiometry, levels of bone turnover markers and calciotropic hormones were estimated from fasting serum samples. Participants with and without T2D were comparable before surgery, with the exception of glycosylated hemoglobin (HbA_1c).

RESULTS

Preoperatively, BMSi was inversely associated with BMI, β_unadjusted -1.1 (-1.9 to -0.28), R²=0.19, p=0.010, and this association remained significant after adjusting for age and gender. After RYGB the participants had lost a mean±SD of 33.9±10.9kg, 48.7±14.2 % of total body fat, increased physical activity, unchanged vitamin D levels, and all but one of the 13 participants with T2D were in diabetes remission. BMSi increased from 78.1±8.5 preoperatively to 82.0±6.4 one year after RYGB, corresponding to an increase of 4.0±9.8 in absolute units or 6.3±14.0 %, p=0.037. The increase was comparable in participants with and without T2D. In subjects with T2D, a larger decrease in HbA_1c was associated with a larger increase in BMSi β_unadjusted -9.2 (-16.5 to -1.9), R²=0.47, p=0.019. Bone turnover markers (CTX-1 and PINP) increased by 195.1±133.5 % and 109.5±70.6 %, respectively. aBMD decreased by 3.9±5.5 % in the lumbar spine, 8.2±4.6 % in the femoral neck, 11.6±4.9 % in total hip and 9.4±3.8 % in total body.

CONCLUSION

Our findings indicate that bone material strength improves despite an increase in bone turnover and a decrease in aBMD one year after RYGB. Trends were statistically comparable in participants with and without T2D. However, improved glucose control was associated with improved bone material strength in participants with T2D.

Pyroptosis in Osteoblasts: A Novel Hypothesis Underlying the Pathogenesis of Osteoporosis

Osteoporosis has become a worldwide disease characterized by a reduction in bone mineral density and the alteration of bone architecture leading to an increased risk of fragility fractures. And an increasing number of studies have indicated that osteoblasts undergo a large number of programmed death events by many different causes in osteoporosis and release NLRP3 and interleukin (e.g., inflammatory factors), which play pivotal roles in contributing to excessive differentiation of osteoclasts and result in exaggerated bone resorption. NLRP3 is activated during pyroptosis and processes the precursors of IL-1β and IL-18 into mature forms, which are released into the extracellular milieu accompanied by cell rupture. All of these compounds are the classical factors of pyroptosis. The cellular effects of pyroptosis are commonly observed in osteoporosis. Although many previous studies have focused on the pathogenesis of these inflammatory factors in osteoporosis, pyroptosis has not been previously evaluated. In this review, pyroptosis is proposed as a novel hypothesis of osteoporosis pathogenesis for the first time, thus providing a new direction for the treatment of osteoporosis in the future.

Comparison of different calcium supplementation methods in patients with osteoporosis

The aim of the present study was to explore the clinical efficacy and safety of different methods of calcium supplementation in osteoporosis (OP). Patients with OP were divided into four groups, including the control, oral calcium supplementation, intravenous calcium supplementation and combined calcium supplementation groups. The duration of the calcium supplementation was 3-6 years. Medical records were collected and examined along with demographic data, the incidence of certain diseases and adverse reactions. All subjects in the three treatment groups exhibited statistically significant reductions in alkaline phosphatase (ALP) levels, visual analog score (VAS) and Oswestry Disability Index (ODI) compared with the respective pre-treatment values. Furthermore, compared with prior to treatment, the lumbar and hip bone mineral density (BMD) of patients receiving intravenous calcium supplementation was significantly increased. In addition, after treatment, the lumbar and hip BMD was significantly increased, whereas ALP levels, VAS and ODI were significantly decreased in the oral calcium supplementation group compared with the control group. Also, compared with the control and oral calcium supplementation groups, the BMD was significantly increased, whereas ALP, VAS, ODI, the rate of infection and tooth loss, the incidence of fragility fractures, joint replacement surgery, arrhythmia, lumbar disc herniation and cerebral infarction were significantly decreased in the two groups treated with intravenous calcium supplementation. The results of the present study may enable a better understanding of the effectiveness and safety of the different methods for supplementing calcium in OP.

Risk factors for vertebral fracture in primary hyperparathyroidism

PURPOSE

Screening for vertebral fractures (VF) in primary hyperparathyroidism (PHPT) is recommended, but there are limited data regarding which patients are at greatest risk for VF. We evaluated risk factors for VF in PHPT.

METHODS

This is a retrospective cross-sectional analysis of 117 participants with PHPT. We assessed Grades 2 and 3 VF by vertebral fracture assessment (VFA) and the association of VF with the trabecular bone score (TBS), other skeletal parameters and clinical risk factors. VFA was performed only in those who met National Osteoporosis Foundation criteria for VFA screening.

RESULTS

T-scores were in the osteopenic range and TBS was degraded. Overall VF rate based on VFA or other imaging was 12.8%. Serum PTH, calcium and TBS were not associated with VF. Those with VF were older (p = 0.04), had worse renal function (p = 0.04), were more likely to have received osteoporosis treatment (p = 0.03), and tended to have had a prior fracture (p = 0.06). T-scores did not differ by fracture status at any skeletal site. Those with VF had nine times the odds of osteoporosis at the hip (95% CI 2.4-34.5), but this risk factor had low sensitivity (46.7%) for VF. Hip T-score < -2.6, Age > 78.6 years, and GFR < 58.8 ml/min/1.73 m² (thresholds maximizing sensitivity and specificity) had areas under the curve of 0.60-0.67 for VF (all p < 0.05) and low sensitivity. Findings were similar when analyses were limited to women.

CONCLUSIONS

In PHPT, VF risk factors included older age, prior fracture, worse renal function and osteoporosis at the hip, but not osteoporosis at other sites, TBS or biochemical indices of PHPT. Since identified risk factors had low sensitivity and were generally inaccurate for categorizing those with VF, the data do not support limiting screening to PHPT patients with these specific VF risk factors.

Changes in Bone Mineral Density Following Weight Loss Induced by One-Anastomosis Gastric Bypass in Patients with Vitamin D Supplementation

BACKGROUND

Little is known about changes in bone mineral density (BMD) following weight loss after one-anastomosis gastric bypass (OAGB) and the role of serum vitamin D and its supplementation on bone metabolism. We evaluated BMD after OAGB as a function of vitamin D supplementation with respect to a minimum threshold of 25-hydroxy-vitamin-D [25(OH)D] concentration, which could prevent or decelerate an eventual bone loss.

METHODS

Fifty bariatric patients who participated in the randomized controlled trial were included in this analysis. BMD and anthropometric measurements by DXA and laboratory parameters were assessed before (T0), at 6 (T6), and 12 months (T12) after surgery.

RESULTS

OAGB resulted in a 36% total body weight loss with a decrease in body fat and an increase in lean body mass. A significant decrease in BMD was seen in lumbar spine by 7%, left hip 13%, and total body 1%, but not in forearm. Bone turnover markers increased significantly but with normal parathyroid hormone concentrations. Weight loss was not associated with changes in BMD. A serum 25(OH)D concentration > 50 nmol/l at T6 and T12 (adequate-vitamin-D-group; AVD) showed a significant lower bone loss, compared to the inadequate-vitamin-D-group (IVD; < 50 nmol/l). Lower bone loss in the left hip showed a strong correlation with higher 25(OH)D concentrations (r = 0.635, p = 0.003).

CONCLUSION

These findings support a dose effect of vitamin D supplementation on bone health and suggest that 25(OH)D concentrations need to be above 50 nmol/l at least during the first postoperative year to decelerate bone loss in patients undergoing OAGB.

CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE

Clinicaltrials.gov (NCT02092376) at https://clinicaltrials.gov /. EudraCT (2013-003546-16) at https://eudract.ema.europa.eu /.

Bone metabolism, bone mineral density and low-energy fractures 10 years after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a common surgical procedure for treatment of morbid obesity. RYGB induces considerable and sustained weight loss, and remission of obesity related-comorbidities. While studies have suggested negative effects of RYGB on bone health, long-term data are lacking. We aimed to evaluate the prevalence of aBMD below the expected range for age, osteopenia, osteoporosis and low-energy fractures in a defined patient cohort 10 years after RYGB. Secondly, we wanted to identify factors associated with increased risk of aBMD z-score or t-score of -1.1 or lower 10 years after RYGB.

METHODS

Patients undergoing RYGB surgery from June 2004 to December 2006 at the Department of Morbid Obesity and Bariatric Surgery, Oslo University Hospital, a tertiary referral centre for treatment of morbid obesity, were invited to a 10 year follow-up. Follow-up visits included morning fasting blood samples, clinical examination, anthropometric measures and dual energy X-ray absorptiometry (DXA).

RESULTS

Out of 194 patients eligible for the study, 124 attended the 10 year follow-up and 122 (63%) were examined with DXA. Mean (SD) age was 50.3 (9.0) years, 118 (97%) were of Caucasian ethnicity, 94 were females (77%), of whom 41 (44%) were postmenopausal. Secondary hyperparathyroidism (SHPT) was noted in 37 participants (31%) and vitamin D deficiency (value below 50 nmol/L) and insufficiency (value below 75 nmol/L) in 40 (33%) and 91 (75%), respectively. Among the 63 participants who were premenopausal females or males 49 years or younger the prevalence of areal bone mineral density (aBMD) in the lower range of normal (z-score -1.1- to -1.9) was 30% (n = 19) and aBMD below the expected range for age (z-score ≤ -2.0) was noted in 8% (n = 5). Among the 59 participants who were postmenopausal females or males 50 years or older, the prevalence of osteopenia (t-score -1.1 to -2.4) was 51% (n = 30) and osteoporosis (t-score ≤ -2.5) was 27% (n = 16). The bone resorption markers CTX-1 and PINP were higher in participants with aBMD z-score or t-score of -1.1 or lower compared to participants with aBMD z-score or t-score of -1.0 or higher. Preoperative hypothyroidism, or higher age, postmenopausal status, BMI < 35 kg/m², SHPT or higher PINP levels at 10 year follow-up were independently associated with aBMD z-score or t-score of -1.1 or lower 10 years after RYGB. Eighteen participants (15%) reported a clinical low-energy fracture after RYGB. In addition, vertebral fracture assessment by DXA revealed that 10 participants (8%) had experienced at least one moderate to severe morphometric vertebral fracture.

CONCLUSION

Ten years after RYGB 27% of postmenopausal females and males 50 years or older were osteoporotic, and 8% of premenopausal females and males 49 years or younger exhibited aBMD below the expected range for age. The prevalence of fragility fractures was high. SHPT, higher age, postmenopausal status or higher PINP levels at 10 years and preoperative hypothyroidism were all independent risk factors for aBMD z-score or t-score of -1.1 or lower 10 years after RYGB.

Discriminative Accuracy of FEV1:FVC Thresholds for COPD-Related Hospitalization and Mortality

Importance

According to numerous current guidelines, the diagnosis of chronic obstructive pulmonary disease (COPD) requires a ratio of the forced expiratory volume in the first second to the forced vital capacity (FEV1:FVC) of less than 0.70, yet this fixed threshold is based on expert opinion and remains controversial.

Objective

To determine the discriminative accuracy of various FEV1:FVC fixed thresholds for predicting COPD-related hospitalization and mortality.

Design, Setting, and Participants

The National Heart, Lung, and Blood Institute (NHLBI) Pooled Cohorts Study harmonized and pooled data from 4 US general population-based cohorts (Atherosclerosis Risk in Communities Study; Cardiovascular Health Study; Health, Aging, and Body Composition Study; and Multi-Ethnic Study of Atherosclerosis). Participants aged 45 to 102 years were enrolled from 1987 to 2000 and received follow-up longitudinally through 2016.

Exposures

Presence of airflow obstruction, which was defined by a baseline FEV1:FVC less than a range of fixed thresholds (0.75 to 0.65) or less than the lower limit of normal as defined by Global Lung Initiative reference equations (LLN).

Main Outcomes and Measures

The primary outcome was a composite of COPD hospitalization and COPD-related mortality, defined by adjudication or administrative criteria. The optimal fixed FEV1:FVC threshold was defined by the best discrimination for these COPD-related events as indexed using the Harrell C statistic from unadjusted Cox proportional hazards models. Differences in C statistics were compared with respect to less than 0.70 and less than LLN thresholds using a nonparametric approach.

Results

Among 24 207 adults in the pooled cohort (mean [SD] age at enrollment, 63 [10.5] years; 12 990 [54%] women; 16 794 [69%] non-Hispanic white; 15 181 [63%] ever smokers), complete follow-up was available for 11 077 (77%) at 15 years. During a median follow-up of 15 years, 3925 participants experienced COPD-related events over 340 757 person-years of follow-up (incidence density rate, 11.5 per 1000 person-years), including 3563 COPD-related hospitalizations and 447 COPD-related deaths. With respect to discrimination of COPD-related events, the optimal fixed threshold (0.71; C statistic for optimal fixed threshold, 0.696) was not significantly different from the 0.70 threshold (difference, 0.001 [95% CI, -0.002 to 0.004]) but was more accurate than the LLN threshold (difference, 0.034 [95% CI, 0.028 to 0.041]). The 0.70 threshold provided optimal discrimination in the subgroup analysis of ever smokers and in adjusted models.

Conclusions and Relevance

Defining airflow obstruction as FEV1:FVC less than 0.70 provided discrimination of COPD-related hospitalization and mortality that was not significantly different or was more accurate than other fixed thresholds and the LLN. These results support the use of FEV1:FVC less than 0.70 to identify individuals at risk of clinically significant COPD.

Body iodine status in women with postmenopausal osteoporosis

OBJECTIVE

Postmenopausal osteoporosis is a frequent cause of morbidity and can negatively impact life expectancy; iodine is an essential element for bone mineralization, and iodine deficiency is frequently observed. The aim of the present study was to understand the connection between postmenopausal osteoporosis and the level of iodine in the body.

METHODS

A total of 132 participants were divided into three groups: group 1 consisted of healthy postmenopausal women (n = 34), group 2 comprised osteopenic women (n = 38), and group 3 included women with postmenopausal osteoporosis (n = 60). The three groups were compared according to demographic, clinical, and laboratory findings.

RESULTS

The urinary iodine levels were recorded as 216.1 ± 125.2 in the control group, 154.6 ± 76.6 in the osteopenic group, and 137.5 ± 64.9 in the postmenopausal osteoporosis group (P < 0.001). These differences were maintained after adjustment for body mass index (P < 0.001). The urinary iodine level accurately correlated with the total T-score for the lumbar spine (r = 0.236, P = 0.008). Multiple regression analysis showed that corrected for body mass index, alkaline phosphatase isoenzyme, and urinary deoxypyridinoline, the urinary iodine level was significantly associated with total T-score (beta coefficient = 0.270, P = 0.006).

CONCLUSIONS

The urinary iodine level was significantly lower in women with postmenopausal osteoporosis, and iodine replacement may be important in preventing osteoporosis in areas where iodine deficiency is endemic.

Development and characterization of supramolecular calcitonin assembly and assessment of its interactions with the bone remodelling process

Osteoporosis is the most common metabolic bone disease, which poses an immense socio-economic burden on the society. Human calcitonin, though safe, is not considered as a therapeutic option because of its high tendency to self-associate to form amyloid fibrils thereby affecting its potency. To circumvent this issue we harnessed the inherent capacity of aggregation and developed an assemblage of human calcitonin monomers, [Supramolecular Calcitonin Assembly (SCAI)], which releases biologically active calcitonin monomers in a sustained manner for a period of at least three weeks. AFM and FT-IR analysis showed that SCA-I is amorphous aggregates of calcitonin monomers. Both SCA-I and monomer released from it demonstrated superior anti-osteoclast activity and proteolytic stability in-vitro. SCA-I upon single injection significantly improved bone formation markers and reduced bone resorption markers in ovariectomized (OVX) rat model of postmenopausal osteoporosis. Micro-CT analysis revealed that calcitonin released from SCA-I exhibits its beneficial effect on cortical bone more profoundly compared to trabecular bone. This study demonstrates that SCA-I is more effective compared to the human calcitonin monomers on osteoclasts and has site-specific effect on bone in a model of post-menopausal osteoporosis. This approach opens up an innovative way to use and study the function of human calcitonin.

The 2018 Guidelines for the diagnosis and treatment of osteoporosis in Greece

We report the updated guidelines for the management of osteoporosis in Greece, which include guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information, and national evidence from Greek clinical practice and the healthcare setting.

PURPOSE

The purpose of this report was to update the Guidelines for the Management of Osteoporosis in Greece that was published in 2011.

METHODS

In line with the GRADE system, the working group initially defined the main clinical questions that should be addressed when dealing with the diagnosis and management of osteoporosis in clinical practice in Greece. Following a literature review and discussion on the experience gained from the implementation of the 2011 Guidelines transmitted through the national electronic prescription network, the Hellenic Society for the Study of Bone Metabolism (HSSBM) uploaded an initial draft for an open dialogue with the relevant registered medical societies and associations on the electronic platform of the Greek Ministry of Health. After revisions, the Central Health Council approved the final document.

RESULTS

The 2018 Guidelines provide comprehensive recommendations on the issues of the timing of fracture risk evaluation and dual-energy X-ray absorptiometry (DXA) measurement, interpretation of the DXA results, the diagnostic work-up for osteoporosis, the timing as well as the suggested medications for osteoporosis treatment, and the follow-up methodology employed during osteoporosis treatment.

CONCLUSIONS

These updated guidelines were designed to offer valid guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information and national evidence from clinical practice and the healthcare setting. Clinical judgment is essential in the management of every individual patient for the purpose of achieving the optimal outcome in the safest possible way.

Dihydrodaidzein and 6-hydroxydaidzein mediate the fermentation-induced increase of antiosteoporotic effect of soybeans in ovariectomized mice

The consumption of soybeans is known to have beneficial effects on osteoporosis in postmenopausal women. However, the effects of soybean fermentation on the bioavailability and the antiosteoporotic effect have not yet been elucidated. To address this question, we fed ovariectomized C57BL/6J mice with a 5% nonfermented raw soybean (RS)- or fermented soybean (FS)-supplemented diet. After 18 wk of treatment, microcomputed tomography showed that FSs significantly increased bone mineral density compared with RSs. This was because of the up-regulation of bone morphogenic protein 2 (Bmp2) and its downstream target osteopontin in bone tissues. We analyzed isoflavone metabolite profiles in the sera of RS- or FS-fed mice and observed that the levels of 19 isoflavone metabolites were significantly increased in the sera of FS-fed mice. Among these metabolites, we observed that both dihydrodaidzein (DHD) and 6-hydroxydaidzein (6-HD) increased osteogenesis via Bmp2 signaling pathway in MC3T3-E1 cells and reduced receptor activator of nuclear factor κ-B ligand-induced osteoclastogenesis in RAW264.7 cells through the inhibition of NF-κB activation and MAPK phosphorylation. These data suggest that improved bioavailability of FSs resulted from the production of active metabolites such as DHD and 6-HD after consumption. DHD and 6-HD can be used as potential therapeutics for the amelioration of osteoporotic bone loss.-Kim, J.-S., Lee, H., Nirmala, F. S., Jung, C. H., Kim, M. J., Jang, Y.-J., Ha, T. Y., Ahn, J. Dihydrodaidzein and 6-hydroxydaidzein mediate the fermentation-induced increase of anti-osteoporotic effect of soybeans in ovariectomized mice.

Comparison of Rigid and Soft-Brace Treatments for Acute Osteoporotic Vertebral Compression Fracture: A Prospective, Randomized, Multicenter Study

While bracing is the standard conservative treatment for acute osteoporotic compression fracture, the efficacy of different brace treatments has not been extensively studied. We aimed to clarify and compare the preventive effect of the different brace treatments on the deformity of the vertebral body and other clinical results in this patient cohort. This multicenter nationwide prospective randomized study included female patients aged 65–85 years with acute one-level osteoporotic compression fractures. We assigned patients within four weeks of injury to either a rigid-brace treatment or a soft-brace treatment. The main outcome measure was the anterior vertebral body compression percentage at 48 weeks. Secondary outcome measures included scores on the European Quality of Life-5 Dimensions (EQ-5D), visual analog scale (VAS) for lower back pain, and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). A total of 141 patients were assigned to the rigid-brace group, whereas 143 patients were assigned to the soft-brace group. There were no statistically significant differences in the primary outcome and secondary outcome measures between groups. In conclusion, among patients with fresh vertebral compression fractures, the 12-week rigid-brace treatment did not result in a statistically greater prevention of spinal deformity, better quality of life, or lesser back pain than soft-brace.

Distal Forearm Bone Mineral Density Among Hill Tribes in the Omkoi District, Chiang Mai Province, Thailand

Background:

Osteoporosis is a major public health issue in several countries worldwide because it increases healthcare costs, and is a risk for mortality. There have been several studies that have examined BMD among the various Thai people and the regions that they inhabit.

Objective:

This study examined the distal forearm Bone Mineral Density (BMD) in men and women over 40 years of age among members of various Karen hill-tribes located in the Omkoi District, Chiang Mai Province, Thailand.

Methods:

Two hundred and sixty-two subjects (180 women, 82 men), ranging from 40 to 83 years old were recruited in this study. The non-dominant distal forearm bone mineral density was assessed by using peripheral dual-energy X-ray absorptiometry (pDEXA).

Results:

The results showed that the BMD were 0.530 ± 0.065, 0.508 ± 0.087, 0.461 ± 0.098, and 0.438 ± 0.124 g/cm2for men age 40-49 years, age 50-59 years, age 60-69 years, and ages 70-83 years, respectively. For women, the BMD were 0.392 ± 0.051, 0.337 ± 0.063, 0.232 ± 0.065, and 0.212 ± 0.069 g/cm2among women age 40-49 years, age 50-59 years, age 60-69 years, and ages 70-83 years, respectively. BMD had decreased in post-menopause as a function of duration time after menopause.

Conclusion:

We determined the prevalence of osteoporosis of men and women of Karen hill-tribes in the Chiang Mai Province, Thailand. These findings provided important information regarding bone health in Karen hill-tribes for any healthcare planning done in the immediate future.

Application of ICF conceptual framework in Osteoporosis

Background: Osteoporosis (OP) is a metabolic bone disease defined by low bone strength and deterioration of bone tissue, which has wide clinical presentations. The World Health Organization's International Classification of Functioning Disability and Health (ICF) provides a common language, classification system, and conceptual framework to describe the consequences of health conditions in terms of body function and structure, activities and participation, environmental and personal factors. Objectives: The ICF conceptual framework was used, in this paper, to integrate OP research-based knowledge into clinical application using clinical vignettes. Results: Body functions and structures, activities and participation, environmental factors and personal factors are described, and the inter-connection among these factors is explored. The vignettes highlight the importance of different components of the ICF framework and to demonstrate how the ICF framework can capture individual differences in how disability can be experienced in OP. Conclusion: The ICF conceptual framework provides a holistic representation of disability by facilitating a critical appraisal of the health status of people with OP. The framework creates an awareness of the broad and multidimensional nature of OP on the health of individual patients, integrates dimensions of functioning, and highlights the complexity of the evaluation and management of OP.

Alkaline phosphatase is a predictor of Bone Mineral Density in postmenopausal females

OBJECTIVES

The study was planned to determine whether serum calcium, phosphate and alkaline phosphatase (ALP) are predictors of bone mineral density (BMD) in postmenopausal non-osteoporotic, osteopenic, and osteoporotic females.

METHODS

In this cross sectional study, conducted at Shaikh Zayed Hospital, Lahore in the year 2014-2015, postmenopausal females between 50-70 years of age were taken and divided into three groups non-osteoporotic (n=52), osteopenic (n=69) and osteoporotic (n=47). Serum ALP, phosphate and calcium were used in a stepwise multiple regression analysis to predict T-score in these groups.

RESULTS

In normal postmenopausal females, the prediction model was statistically significant, F(2, 41) = 6.041, p < 0.05 and showed a T-score variance of 22%. T-score was primarily predicted by higher levels of phosphate and calcium. In postmenopausal osteopenic females, T-score was only predicted by lower levels of ALP. The model was statistically significant, F(1, 59) = 4.995, p < 0.05, and accounted for approximately 7% of the variance of T-score. In postmenopausal osteoporotic females, the prediction model contained no predictors.

CONCLUSION

Our study suggested that calcium and phosphate are the strongest predictors of T-score in postmenopausal normal females, while in postmenopausal osteopenic females ALP was the strongest predictor of T-score. Elevated serum ALP levels may help in determining loss of BMD in postmenopausal females.

Combining information from multiple bone turnover markers as diagnostic indices for osteoporosis using support vector machines

CONTEXT

Osteoporosis (OP) is a progressive systemic bone disease. Dual-energy X-ray absorptiometry (DXA) is routinely employed and is considered the gold standard method for the diagnosis of OP.

OBJECTIVE

We aimed to investigate the potential use of combined information from multiple bone turnover markers (BTMs) as a clinical diagnostic tool for OP.

MATERIALS AND METHODS

A total of 9053 Chinese postmenopausal women (2464 primary OP patients and 6589 healthy controls) were recruited. Serum levels of six common BTMs, including BAP, BSP, CTX, OPG, OST and sRANKL were assayed. Models based on support vector machine (SVM) were constructed to explore the efficiency of different combinations of multiple BTMs for OP diagnosis.

RESULTS

Increasing the number of BTMs used in generating the models increased the predictive power of the SVM models for determining the disease status of study subjects. The highest kappa coefficient for the model with one BTM (BAP) compared to DXA was 0.7783. The full model incorporating all six BTMs resulted in a high kappa coefficient of 0.9786.

CONCLUSION

Our findings showed that although single BTMs were not sufficient for OP diagnosis, appropriate combinations of multiple BTMs incorporated into the SVM models showed almost perfect agreement with the DXA.

Assessing bone mineral changes in response to vitamin D supplementation using natural variability in stable isotopes of Calcium in Urine

Osteoporosis is a chronic disease of public health importance, particularly in low and middle income countries. Measuring the bone mineral balance (BMB) in a non-invasive manner, and its response to different interventions, is critical to the definition of optimal strategies for its prevention and management. In this study, we demonstrate the usefulness of natural variability in calcium isotopes (δ^44/40Ca) of urine and the derived BMB estimates as a biomarker of bone health and its responsiveness to interventions. Vitamin D₃ is commonly used as a supplement for the prevention and treatment of osteoporosis, along with calcium supplements. We studied the effect of a short term vitamin D₃ supplementation on changes in urine δ^44/40Ca and the derived BMB. δ^44/40Ca before and after the vitamin D₃ supplementation yielded a statistically significant change (p = 0.050) with a positive δ^44/40Ca enrichment. The mean derived BMB was net positive (0.04 ± 0.05) in comparison to a net negative value for the control group (−0.03 ± 0.01). These results indicate the potential usefulness of urinary natural δ^44/40Ca and the derived BMB, which, along with bone mineral density could be used as a sensitive marker for precision in the prevention and treatment of osteoporosis.

Bone mineral loss and cognitive impairment: The PRESENT project

Low bone mineral density (BMD) is correlated with Alzheimer's disease and its severity, but the association remains unclear in adults (≥50 years) without a history of stroke or dementia.We assessed BMD and cognitive function using the Mini-Mental Status Examination (MMSE) in 650 stroke- and dementia-free subjects (≥50 years) who were recruited for an early health check-up program between January 2009 and December 2010.The mean age was 62.9 ± 8.0 years and mean MMSE score was 27.6 ± 3.6. A total of 361 subjects had reduced BMD: 197 (30.3%) had osteopenia and 154 (23.6%) had osteoporosis, based on criteria of world health organization. A total of 5.4% of the male subjects had osteoporosis, versus 19.8% of the female subjects. After adjusting for age, sex, education, and other possible confounding factors such as hypertension, diabetes mellitus, and smoking, the estimated odds ratio for cognitive impairment was 1.72 for the osteopenia group (95% confidence interval [CI] 1.09-2.14, P = .019) and 2.81 for the osteoporosis group (95% CI 1.78-4.45, P < .001).Low BMD is correlated with cognitive impairment in community-dwelling adults aged 50 years and above without any medical history of stroke or dementia, especially in women. A community-based, early life, preventive osteoporosis education campaign might decrease the incidence of dementia.

A 10-Year Prospective Study of Bone Mineral Density and Bone Turnover in Males and Females With Type 1 Diabetes

CONTEXT

In a previous community-based, cross-sectional study, males with type 1 diabetes (T1D) had lower bone mineral density (BMD) than did matched people without diabetes but females with T1D had normal BMD.

OBJECTIVE

To determine whether BMD in the males continued to decline, the neutral effect of T1D on BMD in females persisted, and whether temporal BMD changes reflected changes in bone turnover markers.

DESIGN

Longitudinal observational study.

SETTING

Urban community.

PATIENTS

Forty-eight of the original 102 original cross-sectional study participants (20 males, 28 females) of mean age 42.0 years and median diabetes duration 14.6 years at baseline who were restudied a mean of 10.3 years later.

MAIN OUTCOME MEASURES

BMD at total hip, femoral neck, lumbar spine (L1 to L4), and distal forearm. Biochemical bone turnover markers.

RESULTS

After adjustment for age, body mass index (BMI), and renal function, there was no temporal change in BMD at the hip or forearm in the males (P ≥ 0.12), but lumbar spine BMD increased (P = 0.009). Females exhibited no statistically significant change in BMD in similar multivariable models that also included postmenopausal status, except a mild increase at the forearm (P = 0.046). Age- and sex-related changes in bone turnover markers paralleled those in general population studies.

CONCLUSIONS

There is a reduction in BMD in males with T1D that occurs early in the course of the disease but then stabilizes. BMD in females with T1D remains similar to that expected for age, BMI, and postmenopausal status.

A bone-targeting drug-delivery system based on Semaphorin 3A gene therapy ameliorates bone loss in osteoporotic ovariectomized mice

Osteoporosis is a serious health problem worldwide. Semaphorins (Sema) have been described as key molecules involved in the cross-talk between bone cells (osteoblasts/osteoclasts). In this study, we investigated whether plasmid containing Sema3a could ameliorate bone loss in an ovariectomized (OVX) mouse model via (AspSerSer)₆, a selectively bone-targeting moiety. Plasmid pcDNA3.1(+)-Sema3a-GFP was fabricated and transfected cells with the plasmid demonstrated statistically higher levels of Sema3A in vitro (p < 0.001). Mice were ovariectomized and injected twice weekly with (AspSerSer)₆-(STR-R8)+pcDNA3.1(+)-Sema3a-GFP for four weeks. The aim of the study was twofold: firstly to design an effective bone-targeting drug-delivery system (AspSerSer)₆. Secondly, the effects of Sem3A gene therapy on bone loss was investigated. Here, the targeting selectivity of pcDNA3.1(+)-Sema3a-GFP via (AspSerSer)₆ to the trabecular bone surface was firstly verified by histological observation of frozen sections and immunofluorescence staining. Then, bone microstructure analysis by Micro-CT indicated significantly less bone loss in mice treated with (AspSerSer)₆-(STR-R8)+pcDNA3.1(+)-Sema3a-GFP compared to the control group (p < 0.05). Furthermore,H&E staining and Safranin O staining of the decalcified sections demonstrated statistically significantly higher bone area/total area in the mice that were injected with (AspSerSer)₆-(STR-R8)+pcDNA3.1(+)-Sema3a-GFP (p < 0.001, p < 0.01,respectively). TRAP staining and immunohistochemistry staining of COL I demonstrated lower numbers of osteoclasts and significantly increased numbers of osteoblasts in the bone-targeting moiety delivering pcDNA3.1(+)-Sema3a-GFP group, when compared to the control group (p < 0.01, p < 0.001,respectively). Together, our findings have identified that, (AspSerSer)₆, a bone-targeting drug-delivery system based on semaphorin3A gene therapy, ameliorated bone loss in osteoporotic ovariectomized mice, by suppressing osteoclastic bone resorption and simultaneously increasing osteoblastic bone formation. Gene therapy by local site-specific Sema3A overexpression might be a potential new strategy for treating osteoporosis and bone defects.

Low bone mineral density is associated with global coronary atherosclerotic plaque burden in stable angina patients

Background

Accelerated atherosclerosis is considered to be the linking factor between low bone mineral density (BMD) and increased cardiovascular events and mortality, while some coronary angiographic studies do not support this point. In this study, we attempt to provide a distinct comprehensive view of the relationship between BMD and the angiographically determined coronary atherosclerotic burden.

Methods

A total of 459 consecutive patients with stable chest pain suspected of coronary artery disease (CAD) underwent both dual-energy X-ray absorptiometry scan and selective coronary angiography. The association between BMD and global coronary atherosclerotic plaque burden as represented by the multivessel involvement and the modified Gensini score was analyzed.

Results

Multivariable analysis revealed that the low BMD at femoral neck and total hip was an independent correlate of multivessel CAD. The T-scores measured at femoral neck and total hip were both negatively and independently associated to the modified Gensini score. These inversely correlated relationships between BMD and CAD were not observed at lumbar spine 1–4.

Conclusion

This cross-sectional study elucidated an inverse relationship between hip BMD and the modified Gensini score, and low hip BMD values (T-scores) were significantly and independently associated with increased risk of multivessel coronary disease in patients hospitalized for stable chest pain.

Impact of a Professional Nutrition Program on a Female Cross Country Collegiate Athlete: A Case Report

Low caloric intake or excessive energy expenditure can lead to a negative energy balance, which, in female athletes, may result in a condition called the female athlete triad. While several guidelines identified proper nutrition as a first line of treatment, little research has been reported to show the effect of a professional nutrition program (PNP) on the female athlete triad. The purpose of this case report was to measure the short- and long-term effects of a PNP on a female athlete presenting triad characteristics. A 20-year-old female track-and-field athlete at a Division I university who was in negative energy balance and amenorrheic underwent a one-month PNP. Short- and long-term effects measured by a dual X-ray absorptiometry scan prior to and after attending a PNP showed increased total energy intake from 2188 kcals to 3187 kcals, which resulted in an increase in body fat percent (BF%) from 4.7% to 6.7%. However, by the end of four months, energy intake and BF% (5.7% and 6.0%) values were reduced, respectively. After the twelve-month follow-up, BF% was increased (10.5%), suggesting that increasing energy intake to meet energy demands, without compromising athletic training, can be an effective treatment for the female athlete triad.

The Combined Effect of Nonalcoholic Fatty Liver Disease and Metabolic Syndrome on Osteoporosis in Postmenopausal Females in Eastern China

The present study evaluated the potential combined effects of NAFLD and MetS on the development of osteoporosis. The relationship between NAFLD and MetS and osteoporosis was assessed in 938 postmenopausal female participants. Moderate and severe NAFLDs were combined as significant NAFLD (SNAFLD). All the subjects were divided into 4 subgroups based on the status of SNAFLD and MetS. Relative excess risk of interaction (RERI), attributable proportion (AP) of interaction, and synergy index (SI) were used to investigate the additive interaction of those two factors. NAFLD, SNAFLD, and MetS were independent factors for osteoporosis with the adjustment of age and other confounders. The incidence of osteoporosis in MetS (+) SNAFLD (+) group was significantly higher than that in other three groups. RERI was 2.556 (95% CI = 0.475-4.636), AP was 0.454 (95% CI = 0.201-0.706), and SI was 2.231 (95% CI = 1.124 to 4.428), indicating the significant combined interaction of SNAFLD and MetS on the development of osteoporosis. SNAFLD and MetS are independent risk factors for osteoporosis in postmenopausal females, respectively. Moreover, SNAFLD and MetS have an additive effect on the development of osteoporosis.

Risk of osteoporosis after gastrectomy in long-term gastric cancer survivors

INTRODUCTION

Although early detection and successful gastrectomy have improved the survival of patients with gastric cancer, long-term health problems remain troubling. We evaluated the prevalence of osteoporosis and its risk factors in long-term survivors of gastric cancer after gastrectomy.

METHODS

We reviewed the medical records of a tertiary hospital between 2007 and 2014 to identify survivors of gastric cancer who had visited our center at around 5 years after gastrectomy. We evaluated their health status, including bone mineral density (BMD). Dual-energy X-ray absorptiometry was used to measure the BMD of the lumbar spine and femur (total and neck area). The prevalence of osteoporosis, defined by a BMD T score <-2.5, was investigated, and clinical variables associated with the presence of osteoporosis were identified.

RESULTS

A total of 250 survivors were included. The mean age was 54.6 years old, and the median follow-up was 6.0 years. The prevalence of osteoporosis was 34.0% (27.4% for men and 43.6% for women). Older age [odds ratio (OR) 5.50, 95% CI 2.33-13.00], higher alkaline phosphatase levels before gastrectomy (OR 5.67, 95% CI 1.36-23.64), and marked weight loss (≥20%) after gastrectomy (OR 3.59, 95% CI 1.32-9.77) were independently associated with the presence of osteoporosis.

CONCLUSIONS

In our cohort, osteoporosis was commonly observed in long-term survivors of gastric cancer, and several risk factors for it were identified. To reduce the risk of osteoporosis after gastrectomy, maintaining adequate body weight may be necessary.

School-based exercise interventions effectively increase bone mineralization in children and adolescents

Osteoporosis and fragility fractures have become major global public health concerns, and they can be prevented by maximizing peak bone mass during childhood and adolescence with weight-bearing physical activity, which can result in stronger and healthier bones that significantly decrease the risk of osteoporosis and fragility fractures in adulthood and the elderly years. From a public health perspective, implementing weight-bearing physical activity for children and adolescents is best achieved with school-based exercise interventions, and a review of school-based exercise interventions was conducted to determine their effectiveness in increasing bone mineral density (BMD) and/or bone mineral content (BMC). Seventeen studies were reviewed, all school-based exercise interventions utilized jumping exercises, and 15 of the 17 studies found at least one significant increase in measures of BMD and/or BMC for the total body, and/or at the hip, vertebrae, and/or wrist. One study that found no significant differences did report significant increases in bone structural strength, and the other study with no significant differences had exercises that measured and reported the lowest ground reaction forces (GRFs) of only 2–3 times body weight (BW), whereas the other studies that showed significant increase(s) in BMD and/or BMC had exercise with measured and reported GRFs ranging from 3.5 × to 8.8 × BW. School-based exercise interventions are time- and cost-efficient and effective in increasing BMD and/or BMC in children and adolescents, but must incorporate high-intensity exercise, such as high-impact jumping of sufficient GRFs, in order to significantly increase bone mineralization for osteoporosis and fragility fracture prevention later in life.

Evaluation of bone health among epileptic patients using biochemical markers and DEXA scan: an Egyptian study

BACKGROUND

An association between antiepileptic drugs, low bone mineral density (BMD), fractures, and abnormalities in bone metabolism has been suggested for a longer period, although conclusive evidence has not been reported.

METHODS

Thirty epileptic patients and 30 matched healthy subjects participated in the study. Measurements of serum levels of calcium, phosphorus, vitamin D, parathormone, and alkaline phosphatase were done for included subjects. Dual-energy X-ray absorptiometry (DEXA) scan was also performed.

RESULTS

Serum calcium, phosphorus, and vitamin D were significantly lower, whereas serum parathormone and alkaline phosphatase were significantly higher in epileptic patients compared to control subjects. Bone mineral density (BMD) abnormalities were detected in 22 patients (73.4%). A statistically significant difference in DEXA scan measurements at different regions was detected between epileptic patients and control subjects. Epileptic patients receiving enzyme inducer antiepileptic drugs (AEDs) had significantly lower serum (calcium, phosphorous, and vitamin D) and lower BMD values compared to those receiving enzyme inhibitors. Results of BMD were positively correlated with serum calcium, phosphorous, and vitamin D, while negatively correlated with serum alkaline phosphatase and duration of therapy.

CONCLUSIONS

Abnormal bone health is common in epileptic patients. These abnormalities may be attributed to prolonged intake of AEDs especially enzyme inducers.

Aromatherapy for Sexual Problems in Menopausal Women: A Systematic Review and Meta-analysis

Objectives

The aim of the present systematic review and meta-analysis is the exploration of the potential evidence of the effectiveness of aromatherapy products on the sexual function of menopausal women.

Methods

From inception to December 2017, the search process was performed using the MEDLINE and Scopus databases and the Cochrane Library regarding the trials on the effectiveness of herbal-medicine aromatherapy on the sexual function of menopausal women.

Results

Three of the trials comprise suitable data for inclusion in the meta-analysis. According to the meta-analysis, it is possible to improve the standardized mean difference (SMD) of the sexual desire up to 0.56 in the aromatherapy group compared with the control group (SMD = 0.56; P < 0.001; heterogeneity; I² = 42%; P = 0.141). According to one of the trials, the serum-estrogen level of two different doses did not change in the neroli oil inhalation group compared with the almond-oil group.

Conclusions

Both aromatherapy with neroli oil or lavender (monopreparation) and combined-oil aromatherapy with lavender, fennel, geranium, and rose significantly improved human sexual function; however, a significant change of the serum-estrogen level was not detected. The findings of the present review should be presented cautiously because of the corresponding limitations such as the lack of a standardized tool, the lack of intention-to-treat reporting, the low study amount, and the short-term follow-up.

ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density

Osteoporosis is a considerable public health risk, with 50% of women and 20% of men >50 years of age experiencing fracture, with mortality rates of 20% within the first year. Dual x-ray absorptiometry (DXA) is the primary diagnostic modality by which to screen women >65 years of age and men >70 years of age for osteoporosis. In postmenopausal women <65 years of age with additional risk factors for fracture, DXA is recommended. Some patients with bone mineral density above the threshold for treatment may qualify for treatment on the basis of vertebral body fractures detected through a vertebral fracture assessment scan, a lateral spine equivalent generated from a commercial DXA machine. Quantitative CT is useful in patients with advanced degenerative bony changes in their spines. New technologies such as trabecular bone score represent an emerging role for qualitative assessment of bone in clinical practice. It is critical that both radiologists and referring providers consider osteoporosis in their patients, thereby reducing substantial morbidity, mortality, and cost to the health care system. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Regulatory Perspectives in Pharmacometric Models of Osteoporosis

Osteoporosis is a disorder of the bones in which they are weakened to the extent that they become more prone to fracture. There are various forms of osteoporosis: some of them are induced by drugs, and others occur as a chronic progressive disorder as an individual gets older. As the median age of the population rises across the world, the chronic form of the bone disease is drawing attention as an important worldwide health issue. Developing new treatments for osteoporosis and comparing them with existing treatments are complicated processes due to current acceptance by regulatory authorities of bone mineral density (BMD) and fracture risk as clinical end points, which require clinical trials to be large, prolonged, and expensive to determine clinically significant impacts in BMD and fracture risk. Moreover, changes in BMD and fracture risk are not always correlated, with some clinical trials showing BMD improvement without a reduction in fractures. More recently, bone turnover markers specific to bone formation and resorption have been recognized that reflect bone physiology at a cellular level. These bone turnover markers change faster than BMD and fracture risk, and mathematically linking the biomarkers via a computational model to BMD and/or fracture risk may help in predicting BMD and fracture risk changes over time during the progression of a disease or when under treatment. Here, we discuss important concepts of bone physiology, osteoporosis, treatment options, mathematical modeling of osteoporosis, and the use of these models by the pharmaceutical industry and the Food and Drug Administration.

A systematic review and economic evaluation of bisphosphonates for the prevention of fragility fractures

BACKGROUND

Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture.

OBJECTIVES

To evaluate the clinical effectiveness and safety of bisphosphonates [alendronic acid (Fosamax^® and Fosamax^® Once Weekly, Merck Sharp & Dohme Ltd), risedronic acid (Actonel^® and Actonel Once a Week^®, Warner Chilcott UK Ltd), ibandronic acid (Bonviva^®, Roche Products Ltd) and zoledronic acid (Aclasta^®, Novartis Pharmaceuticals UK Ltd)] for the prevention of fragility fracture and to assess their cost-effectiveness at varying levels of fracture risk.

DATA SOURCES

For the clinical effectiveness review, six electronic databases and two trial registries were searched: MEDLINE, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science and BIOSIS Previews, Clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform. Searches were limited by date from 2008 until September 2014.

REVIEW METHODS

A systematic review and network meta-analysis (NMA) of effectiveness studies were conducted. A review of published economic analyses was undertaken and a de novo health economic model was constructed. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years (QALYs) for each bisphosphonate treatment strategy and a strategy of no treatment for a simulated cohort of patients with heterogeneous characteristics. The model was populated with effectiveness evidence from the systematic review and NMA. All other parameters were estimated from published sources. A NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture^® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX^® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net benefit (INB) was estimated using non-parametric regression. Probabilistic sensitivity analysis (PSA) and scenario analyses were used to assess uncertainty.

RESULTS

Forty-six randomised controlled trials (RCTs) were included in the clinical effectiveness systematic review, with 27 RCTs providing data for the fracture NMA and 35 RCTs providing data for the femoral neck bone mineral density (BMD) NMA. All treatments had beneficial effects on fractures versus placebo, with hazard ratios varying from 0.41 to 0.92 depending on treatment and fracture type. The effects on vertebral fractures and percentage change in BMD were statistically significant for all treatments. There was no evidence of a difference in effect on fractures between bisphosphonates. A statistically significant difference in the incidence of influenza-like symptoms was identified from the RCTs for zoledronic acid compared with placebo. Reviews of observational studies suggest that upper gastrointestinal symptoms are frequently reported in the first month of oral bisphosphonate treatment, but pooled analyses of placebo-controlled trials found no statistically significant difference. A strategy of no treatment was estimated to have the maximum INB for patients with a 10-year QFracture risk under 1.5%, whereas oral bisphosphonates provided maximum INB at higher levels of risk. However, the PSA suggested that there is considerable uncertainty regarding whether or not no treatment is the optimal strategy until the QFracture score is around 5.5%. In the model using FRAX, the mean INBs were positive for all oral bisphosphonate treatments across all risk categories. Intravenous bisphosphonates were estimated to have lower INBs than oral bisphosphonates across all levels of fracture risk when estimated using either QFracture or FRAX.

LIMITATIONS

We assumed that all treatment strategies are viable alternatives across the whole population.

CONCLUSIONS

Bisphosphonates are effective in preventing fragility fractures. However, the benefit-to-risk ratio in the lowest-risk patients may be debatable given the low absolute QALY gains and the potential for adverse events. We plan to extend the analysis to include non-bisphosphonate therapies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013006883.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Risk assessment of effects of cadmium on human health (IUPAC Technical Report)

Chemistry and Human Health, Division VII of the International Union on Pure and Applied Chemistry (IUPAC), provides guidance on risk assessment methodology and, as appropriate, assessment of risks to human health from chemicals of exceptional toxicity. The aim of this document is to describe dose-response relationships for the health effects of low-level exposure to cadmium, in particular, with an emphasis on causation. The term “cadmium” in this document includes all chemical species of cadmium, as well as those in cadmium compounds. Diet is the main source of cadmium exposure in the general population. Smokers and workers in cadmium industries have additional exposure. Adverse effects have been shown in populations with high industrial or environmental exposures. Epidemiological studies in general populations have also reported statistically significant associations with a number of adverse health effects at low exposures. Cadmium is recognized as a human carcinogen, a classification mainly based on occupational studies of lung cancer. Other cancers have been reported, but dose-response relationships cannot be defined. Cardiovascular disease has been associated with cadmium exposure in recent epidemiological studies, but more evidence is needed in order to establish causality. Adequate evidence of dose-response relationships is available for kidney effects. There is a relationship between cadmium exposure and kidney effects in terms of low molecular mass (LMM) proteinuria. Long-term cadmium exposures with urine cadmium of 2 nmol mmol−1 creatinine cause such effects in a susceptible part of the population. Higher exposures result in increases in the size of these effects. This assessment is supported by toxicokinetic and toxicodynamic (TKTD) modelling. Associations between urine cadmium lower than 2 nmol mmol−1 creatinine and LMM proteinuria are influenced by confounding by co-excretion of cadmium with protein. A number of epidemiological studies, including some on low exposures, have reported statistically significant associations between cadmium exposure and bone demineralization and fracture risk. Exposures leading to urine cadmium of 5 nmol mmol−1 creatinine and more increase the risk of bone effects. Similar associations at much lower urine cadmium levels have been reported. However, complexities in the cause and effect relationship mean that a no-effect level cannot be defined. LMM proteinuria was selected as the critical effect for cadmium, thus identifying the kidney cortex as the critical organ, although bone effects may occur at exposure levels similar to those giving rise to kidney effects. To avoid these effects, population exposures should not exceed that resulting in cadmium values in urine of more than 2 nmol mmol−1 creatinine. As cadmium is carcinogenic, a ‘safe’ exposure level cannot be defined. We therefore recommend that cadmium exposures be kept as low as possible. Because the safety margin for toxic effects in kidney and bone is small, or non-existent, in many populations around the world, there is a need to reduce cadmium pollution globally.

Characteristics of bone biochemical indices in predicting secondary osteoporotic fracture after intertrochanteric fracture in elderly women

BACKGROUND

This study aimed to explore the characteristics of bone biochemical indices, including bone mineral density (BMD), metabolic markers in elderly women with osteoporotic intertrochanteric fracture and their relevance in secondary fracture.

METHODS

The standard for follow-up from 58 elderly women was established to analyse the BMD in the injured hip, healthy hip, and the vertebra at 1 week and 12 months after fracture. The serum levels of total procollagen type N-terminal propeptide (tPINP) and the age-related type I cross linked C-telopeptide (β-CTX) were recorded and compared between those patients with and without secondary fractures within 12 months.

RESULTS

Twelve months after fracture, the serum levels of tPINP and β-CTX were significantly higher than the baseline values (p < 0.01). The tPINP baseline in patients with secondary fracture was significantly lower than that in the rest patients without secondary fracture (p < 0.01). The β-CTX baseline was notably higher than that without secondary fracture (p < 0.01). BMD values of the three periods had no significantly difference.

CONCLUSION

The serum levels of tPINP and β-CTX are of great value in earlier and more sensitively reflecting the condition of bone turnover in body. Meanwhile, they can predict the subsequent fracture risk more accurately combined with a lower BMD.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

Besides BMD, bone microstructure and remodeling levels can be accurately measured by bone biochemical indices. The main objective of this research is to explore the change of BMD and the serum level of bone biochemical indices of elderly women who suffered unilateral intertrochanteric fracture within 12 months. Simultaneously, with aim to better obtain bone remodeling level and predict more accurately the risk of a secondary osteoporotic fracture, bone biochemical indices of these patients, who undergo secondary osteoporotic fracture or not, are collected during follow-up and compared respectively.

Difference of clinical course between cases with bone union and those with delayed union following osteoporotic vertebral fractures

In this prospective multicenter study of osteoporotic vertebral fractures (OVFs), delayed union of OVF at 6-month follow-up caused prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.

PURPOSE

Delayed union following osteoporotic vertebral fracture displayed as an intravertebral cleft on plain X-rays was reported to be a factor for prolonged severe pain. However, the difference of clinical course between bone union and delayed union cases still remains unclear. The purpose of this study was to identify how OVF delayed union following conventional conservative treatment influences the clinical course with a prospective multicenter study.

METHODS

A total of 324 OVF patients from 25 institutes in Osaka, Japan, were included in the study. At the 6-month follow-up after initial visit to each institute, the patients were classified into bone union and delayed union groups based on plain X-ray findings. The outcome assessments included a VAS for back pain, SF-36 for quality of life (QOL), severity of bed-ridden state for activities of daily living (ADL), MMSE for cognitive functions, and degree of vertebral collapse on plain X-rays.

RESULTS

Overall, 280 patients were included into the union group and 44 into the delayed union group. The VAS score at 6 months was significantly worse in the delayed union group (p = 0.01). The scores for the SF-36 scales of physical functioning and bodily pain at 6 months were significantly lower in the delayed union group (p = 0.019, p = 0.01, respectively). The percentage of nearly or completely bed-ridden patients was significantly higher in the delayed union group. The percentage of newly developed cognitive impairment was significantly higher in the delayed union group (p = 0.02). Progression of vertebral collapse during the 6-month follow-up was more pronounced in the delayed union group (p < 0.01).

CONCLUSION

The present results revealed that delayed union following OVF causes prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.