Accuracy of height loss during prospective monitoring for detection of incident vertebral fractures

Association between Height-Changing Scores and Risk of Sarcopenia Estimated from Anthropometric Measurements in Older Adults: A Cross-Sectional Study

Anthropometric assessments are commonly used to diagnose sarcopenia in older adults. However, the ongoing exploration of novel approaches aims to improve the early detection of sarcopenia. This study investigated the association between the height-changing score (HCS) and the risk of sarcopenia defined by anthropometric measurements in 340 older adults (mean age: 66.2 years). The HCS derived from the difference in height and demi-span equivalent height (DEH) was used as an indicator of declining height in the older adults. Multivariate logistic regression analysis revealed a significant association between the HCS and the risk of sarcopenia in both male and female older adults (OR = 1.146, 95% CI [1.021, 1.286], p = 0.021). In addition, income, BMI, and nutritional status were significantly associated with the risk of sarcopenia (OR = -1.933, 95% CI [0.271, 0.986], p = 0.045; OR = -2.099, 95% CI [0.386, 0.587], p < 0.001; OR = -1.443, 95% CI [0.555, 0.866], p = 0.001, respectively). The white blood cell count, lymphocyte count, and HDL cholesterol were blood biomarkers significantly correlated with calf circumference. It can be suggested that the HCS acts as an indicator and screening tool for sarcopenia risk in older adults, highlighting the potential impact of decreased height on muscle mass loss. Encouraging nutritional support can help mitigate the risk of sarcopenia.

Age-Dependent Association of Height Loss with Incident Fracture Risk in Postmenopausal Korean Women

BACKGRUOUND

Height loss is a simple clinical measure associated with increased fracture risk. However, limited data exists on the association between height loss and fracture risk in postmenopausal Korean women. It is unknown whether this association varies with age.

METHODS

Data on height loss over a 6-year period were collected from a community-based longitudinal follow-up cohort (Ansung cohort of the Korean Genome and Epidemiology Study). Incident fractures were defined based on self-reported fractures after excluding those due to severe trauma or toes/fingers. The association between incident fractures and height loss was investigated using a Cox proportional hazards model.

RESULTS

During a median follow-up of 10 years after the second visit, 259/1,806 participants (median age, 64 years) experienced incident fractures. Overall, a 1 standard deviation (SD) decrease in height (1.6 cm/median 5.8 years) was associated with 9% increased risk of fracture (hazard ratio [HR], 1.09; P=0.037), which lost statistical significance after adjustment for covariates. When stratified into age groups (50-59, 60-69, 70 years or older), a 1 SD decrease in height remained a robust predictor of fracture in the 50 to 59 years age group after adjusting for covariates (adjusted hazard ratio [aHR], 1.52; P=0.003), whereas height loss was not an independent predictor of fracture in the 60 to 69 (aHR, 1.06; P=0.333) or the 70 years or older age groups (aHR, 1.05; P=0.700; P for interaction <0.05, for all).

CONCLUSION

Height loss during the previous 6 years was associated with an increased 10-year fracture risk in postmenopausal women in their 50s.

Height loss is associated with decreased kidney function: The Japan Specific Health Checkups (J-SHC) Study

AIM

Height loss that occurs with aging is a common phenomenon associated with musculoskeletal abnormalities, such as osteoporosis and sarcopenia. Notably, such height loss is also associated with poor outcomes, including cardiovascular disease and mortality. In this study, we investigated the relationship between height loss and kidney outcome.

METHODS

This longitudinal study includes data from the Japan Specific Health Checkups Study from 2008 to 2014. Height loss was estimated using the first three visits (visits 1-3), and kidney outcomes were evaluated using data from the following visits (visit 3 to the last visit). The annual height change for each participant was estimated using mixed-effects model, and participants were divided into five groups according to the quintile of the rate. The association between height change and the incidence of 1.5-fold increase in serum creatinine level from baseline was analyzed using Cox regression analysis. The decline rates of estimated glomerular filtration rate among the groups were compared using a mixed-effects model.

RESULTS

In total, 187 682 participants were included in the analyses. The median rate of height change was -0.11 cm/year. The adjusted hazard ratio (95% confidence interval) for 1.5-fold increase in serum creatinine level in participants with the steepest category of height decline (Q1; Quintile 1) was 1.45 (1.26-1.67) compared with the reference (Q4; Quintile 4). The decline of the estimated glomerular filtration rate in Q1 (-1.25 mL/min/1.73 m² /year) was significantly higher than that of the reference: Q4 (-0.92 mL/min/1.73 m² /year) (P for interaction <0.001).

CONCLUSION

Height loss is associated with a rapid decline in kidney function. Geriatr Gerontol Int 2023; ••: ••-••.

A summary of the Russian clinical guidelines on the diagnosis and treatment of osteoporosis

Key statements of the Russian clinical guidelines on the diagnosis and treatment of osteoporosis are summarized. They were developed by a task force representing the key Russian professional associations involved in the management of osteoporosis and approved by the Russian Ministry of Health.

PURPOSE

To summarize key statements of the Russian clinical practice guidelines for the diagnosis and treatment of osteoporosis.

METHODS

The Russian clinical guidelines on the diagnosis and treatment of osteoporosis were developed by a task force representing the key Russian professional associations involved in the management of osteoporosis: These comprised the Russian Association of Endocrinologists, the Russian Association for Osteoporosis, the Association of Rheumatologists of Russia, the Association of Orthopedic surgeons and Traumatologists of Russia, the Russian Association of Gynecologists-Endocrinologists, and the Russian Association of Gerontologists and Geriatrics. The guidelines are based on a systematic literature review and principles of evidence-based medicine and were compiled in accordance with the requirements for clinical recommendations developed by the Ministry of Health of the Russian Federation.

RESULTS

Key statements included in the Russian guidelines of osteoporosis approved by the Russian Ministry of Health in 2021 are summarized. The statements are graded based on levels of evidence and supported by short comments. The guidelines are focused on the current approach to screening, diagnosis, differential diagnosis, and treatment of osteoporosis.

CONCLUSION

These guidelines are a practical tool for general practitioners, as well as medical specialists, primarily endocrinologists, rheumatologists, orthopedic surgeons, and other physicians who are involved in the management of patients with osteoporosis.

Loss of height predicts fall risk in elderly Japanese: a prospective cohort study

INTRODUCTION

The purpose of this study was to explore whether height loss is associated with future falls and whether the combination of height loss and fall experience is associated with future falls.

MATERIALS AND METHODS

In this prospective observational study, a total of 765 individuals (354 men, 411 women) agreed to join the study. Baseline data on demographics, comorbidities, physical performance, and previous falls were assessed. Height loss was calculated as the difference between the self-reported height at a younger age and the current height and was divided into two groups: < 2 cm and ≥ 2 cm. Approximately 15 months after the baseline evaluation, follow-up questionnaires were used to assess the fall history. Participants were classified as either "non-fallers" or "fallers." Multiple logistic regression was used to evaluate the association between falls and each factor and to obtain adjusted odds ratio estimates.

RESULTS

The follow-up questionnaire was returned by 668 participants, 74 of whom (11.1%) fell at least once during the observation period. Multiple logistic regression analysis found that height loss of > 2 cm was a significant predictor of future falls, even after adjusting for other factors. Additionally, the combination of height loss and previous falls was a risk factor for falls.

CONCLUSIONS

We suggest that height loss of ≥ 2 cm is a predictor of future falls in older adults, and the combination of height loss and fall experiences may be a useful screening tool for determining fall risk.

Height loss as an indicator of ageing through its association with frailty and sarcopenia: An observational cohort study

BACKGROUND

Height loss is associated with various health-related variables such as cardiovascular disease, osteoporosis, cognitive function, and mortality. We hypothesized that height loss can be used as an indicator of aging, and we assessed whether the degree of height loss for 2 years was associated with frailty and sarcopenia.

METHODS

This study was based on a longitudinal cohort, the Pyeongchang Rural Area cohort. The cohort included people aged 65 years or older, ambulatory, and living at home. We divided individuals according to the ratio of height change (height change for 2 years divided by height at 2 years from baseline): HL2 (<-2%), HL1 (-2%--1%), and REF (-1%≤). We compared the frailty index, diagnosis of sarcopenia after 2 years from baseline, and the incidence of a composite outcome (mortality and institutionalization).

RESULTS

In total, 59 (6.9%), 116 (13.5%), and 686 (79.7%) were included in the HL2, HL1, and REF groups, respectively. Compared with the REF group, groups HL2 and HL1 had a higher frailty index, and higher risks of sarcopenia and composite outcome. When groups HL2 and HL1 were merged, the merged group had higher frailty index (standardized B, 0.06; p = 0.049), a higher risk of sarcopenia (OR, 2.30; p = 0.006), and a higher risk of composite outcome (HR, 1.78; p = 0.017) after adjusting for age and sex.

CONCLUSIONS

Individuals with greater height loss were frailer, more likely to be diagnosed with sarcopenia and had worse outcomes regardless of age and sex.

Zoledronate Reduces Height Loss Independently of Vertebral Fracture Occurrence in a Randomized Trial in Osteopenic Older Women

Vertebral fractures are associated with height loss, reduced quality of life, and increased mortality and are an important endpoint for osteoporosis trials. However, height loss is associated with quality of life and mortality independent of associations with fracture. We have used data from a recent 6-year trial of zoledronate in 2000 osteopenic women aged >65 years to assess the impact of the semiquantitative and quantitative components of the definition of vertebral fracture on the outcome of that trial, to determine what factors impacted on height loss and to test whether height loss can be used as a surrogate for vertebral fracture incidence. In the trial protocol, an incident vertebral fracture was defined as a change in Genant grade plus both a 20% and 4 mm decrease in a vertebral height. The addition of the quantitative criteria reduced the number of fractures detected but did not change the size of the anti-fracture effect (odds ratios of 0.49 versus 0.45) nor the width of the confidence intervals for the odds ratios. Multivariate analysis of baseline predictors of height change showed that age accelerated height loss (p < 0.0001) and zoledronate reduced it (p = 0.0001). Incident vertebral fracture increased height loss (p = 0.0005) but accounted for only 0.7% of the variance in height change, so fracture could not be reliably inferred from height loss. In women without incident vertebral fractures, height loss was still reduced by zoledronate (height change: zoledronate, -1.23; placebo -1.51 mm/yr, p < 0.0001). This likely indicates that zoledronate prevents a subtle but widespread loss of vertebral body heights not detected by vertebral morphometry. Because height loss is associated with quality of life and mortality independent of associations with fracture, it is possible that zoledronate impacts on these endpoints via its effects on vertebral body integrity. © 2022 American Society for Bone and Mineral Research (ASBMR).

Definition of normal vertebral morphometry using NHANES‐II radiographs

A robust definition of normal vertebral morphometry is required to confidently identify abnormalities such as fractures. The Second National Health and Nutrition Examination Survey (NHANES‐II) collected a nationwide probability sample to document the health status of the United States. Over 10,000 lateral cervical spine and 7,000 lateral lumbar spine X‐rays were collected. Demographic, anthropometric, health, and medical history data were also collected. The coordinates of the vertebral body corners were obtained for each lumbar and cervical vertebra using previously validated, automated technology consisting of a pipeline of neural networks and coded logic. These landmarks were used to calculate six vertebral body morphometry metrics. Descriptive statistics were generated and used to identify and trim outliers from the data. Descriptive statistics were tabulated using the trimmed data for use in quantifying deviation from average for each metric. The dependency of these metrics on sex, age, race, nation of origin, height, weight, and body mass index (BMI) was also assessed. There was low variation in vertebral morphometry after accounting for vertebrae (eg, L1, L2), and the R² was high for ANOVAs. Excluding outliers, age, sex, race, nation of origin, height, weight, and BMI were statistically significant for most of the variables, though the F‐statistic was very small compared to that for vertebral level. Excluding all variables except vertebra changed the ANOVA R² very little. Reference data were generated that could be used to produce standardized metrics in units of SD from mean. This allows for easy identification of abnormalities resulting from vertebral fractures, atypical vertebral body morphometries, and other congenital or degenerative conditions. Standardized metrics also remove the effect of vertebral level, facilitating easy interpretation and enabling data for all vertebrae to be pooled in research studies. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1

PURPOSE

To provide updated evidence-based recommendations for the prevention, screening, and diagnosis of postmenopausal osteoporosis.

TARGET POPULATION

Postmenopausal patients without identified risk factors for fracture, low bone mineral density, or secondary osteoporosis related to medication or a medical condition.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Gynecology and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within the Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team on the basis of standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations, Assessment, Development and Evaluations) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes updated recommendations on the role of exercise, calcium, and vitamin D in osteoporosis prevention; osteoporosis screening and diagnosis; rescreening intervals; and interventions to prevent falls. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Different cutoff points to diagnose low muscle mass and prediction of osteoporosis in postmenopausal women

OBJECTIVE

This study aimed to verify which of the different cutoff points of low muscle mass (LMM) based on appendicular lean mass (ALM) is associated with osteoporosis in postmenopausal women (PMW).

METHODS

Cross-sectional study. PMW (n = 355) were classified for the presence of osteoporosis (score <-2.5 standard deviations) at the femoral neck and lumbar spine and LMM (three cutoff points: ALM < 15 kg; ALM/height2 [ALM index] <5.67 kg/m2 and ratio between ALM and body mass index [ALMBMI] <0.512).

RESULTS

After adjustments for confounding factors, binary logistic regression showed that ALM and ALM index were associated with osteoporosis at the lumbar spine (odds ratio [OR] = 5.3 [95% CI: 2.3-12.5] and OR = 2.5 [95% CI: 1.0-6.2], respectively) and only ALM was associated with osteoporosis at the femoral neck (OR = 16.1 [95% CI: 4.1-62.5]). When women were classified as having osteoporosis in at least one site, only ALM was associated with osteoporosis (OR = 7.7 [95% CI: 3.3-15.6]). There was no association between ALMBMI and osteoporosis. The predictive value of ALM for osteoporosis decreased after BMI or height were included as a covariate in the model.

CONCLUSION

Absolute ALM (<15 kg) seems to be the most suitable for predicting osteoporosis based on LMM in PMW.

Implications of historical height loss for prevalent vertebral fracture, spinal osteoarthritis, and gastroesophageal reflux disease

We recently uncovered an association between spinal osteoarthritis and height loss that was independent of incident vertebral fracture. However, the optimal cut-off value of historical height loss (HHL) for discriminating spinal osteoarthritis has not been reported. This cross-sectional study aimed to evaluate the implications of HHL for prevalent vertebral fracture, spinal osteoarthritis, and other co-morbidities in postmenopausal women from the Nagano Cohort Study. In total, 942 Japanese postmenopausal outpatients (mean age: 66.7 years) were investigated. HHL was estimated by arm span - body height difference. Multiple logistic regression analysis revealed significant independent associations of HHL with prevalent vertebral fracture (odds ratio [OR] 1.89; 95% confidence interval [CI] 1.55-2.29), spinal osteoarthritis (OR 1.57; 95% CI 1.31-1.88), and gastroesophageal reflux disease (GERD) (OR 1.75; 95% CI 1.34-2.28) after adjustment for other confounders. Receiver operating characteristic curve analysis of HHL was conducted to discriminate the prevalence of co-morbidities. The optimal cut-off value as defined by the Youden index for prevalent vertebral fracture, spinal osteoarthritis, and GERD was 4.95 cm (area under the curve [AUC] 0.740; 95% CI 0.704-0.776), 2.75 cm (AUC 0.701; 95% CI 0.667-0.735), and 5.35 cm (AUC 0.692; 95% CI 0.629-0.754), respectively. Better understanding of the above relationships and proposed cut-off values will be useful for improving the diagnosis, care management, and quality of life in elderly patients.

Spinal Osteoarthritis Is Associated With Stature Loss Independently of Incident Vertebral Fracture in Postmenopausal Women

STUDY DESIGN

Retrospective observational study from the Nagano Cohort Study.

OBJECTIVE

Clarify the association between spinal osteoarthritis and loss of stature in postmenopausal women.

SUMMARY OF BACKGROUND DATA

Loss of stature with aging is known to deteriorate health-related quality of life and has been implicated with increased mortality. Although the association of vertebral fracture with height loss has been well documented, the relationship between stature loss and spinal osteoarthritis remains unclear.

METHODS

We retrospectively investigated Japanese postmenopausal women recruited from the Nagano Cohort Study. The participants were outpatients at a primary care institute in Nagano prefecture, Japan. A total of 977 postmenopausal patients (mean age: 65.8 yr) completed a minimum of 1 year of follow-up, with an average observation period of 7.6 years. Quartile analysis on the prevalence of spinal osteoarthritis and occurrence of incident fracture was performed based on the rate of stature change per year (Δ cm/yr). Multiple regression analysis was also conducted to identify the determinants of stature change.

RESULTS

The lower quartiles of stature change rate (i.e., more rapid stature loss) displayed a significantly higher prevalence of spinal osteoarthritis (P < 0.001) and incident vertebral fracture (P < 0.001). A statistically significant independent negative association for spinal osteoarthritis prevalence with change in stature was revealed by multiple regression analysis after adjusting for confounders including incident vertebral fracture. The partial regression coefficient for spinal osteoarthritis was -0.18 (95% confidence interval -0.33 to -0.03; P = 0.016).

CONCLUSION

This study demonstrated an independent association of spinal osteoarthritis with stature loss in postmenopausal women. Adequate understanding of this relationship and appropriate treatment approaches will help improve health-related quality of life in elderly patients.

LEVEL OF EVIDENCE

3.

Association of height loss with falls and sarcopenia in community-dwelling older women

Objectives

Height loss is associated with vertebral fracture risk and osteoporosis. We assumed that height loss may indicate the risk of falls because the presence of osteoporosis is significantly associated with sarcopenia development. We studied the association of height loss with falls and sarcopenia.

Methods

This study included 610 community-dwelling women. We measured the height, weight, appendicular skeletal muscle mass index (ASMI), grip strength, and gait speed. Additionally, we recorded the individual’s tallest height, and the presence or absence of single or multiple falls during the preceding 12 months. The participants were classified into nonheight loss, 2- to 3-cm height loss, 3- to 4-cm height loss, and over 4-cm height loss groups. The association of height loss with falls and sarcopenia were examined using multiple logistic regression analysis.

Results

We found that 3- to 4-cm height loss and over 4-cm height loss were significantly associated with falls (odds ratio [OR], 1.637; 95% confidence interval [CI], 1.023–2.619; P = 0.04), (OR, 1.742, 95% CI, 1.054–2.877; P = 0.03), respectively. Additionally, over 4-cm height loss was significantly associated with sarcopenia for ASMI calculated by participant’s tallest recalled height squared (OR, 2.676; 95% CI, 1.122–6.284; P = 0.026).

Conclusions

We found that the risk of falls was advanced at 3- to 4-cm height loss and over 4-cm height loss, and sarcopenia started at over 4-cm height loss. Height loss may be a useful indicator of the risk of falls and sarcopenia.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS-2020 UPDATE

Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). Methods: Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high-risk features, a new dual-action therapy option, and transitions from therapeutic options. Conclusion: This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of post-menopausal osteoporosis. Abbreviations: 25(OH)D = 25-hydroxyvitamin D; AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AFF = atypical femoral fracture; ASBMR = American Society for Bone and Mineral Research; BEL = best evidence level; BMD = bone mineral density; BTM = bone turnover marker; CI = confidence interval; CPG = clinical practice guideline; CTX = C-terminal telopeptide type-I collagen; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = U.S. Food and Drug Administration; FRAX® = Fracture Risk Assessment Tool; GI = gastrointestinal; HORIZON = Health Outcomes and Reduced Incidence with Zoledronic acid ONce yearly Pivotal Fracture Trial (zoledronic acid and zoledronate are equivalent terms); ISCD = International Society for Clinical Densitometry; IU = international units; IV = intravenous; LSC = least significant change; NOF = National Osteoporosis Foundation; ONJ = osteonecrosis of the jaw; PINP = serum amino-terminal propeptide of type-I collagen; PTH = parathyroid hormone; R = recommendation; ROI = region of interest; RR = relative risk; SD = standard deviation; TBS = trabecular bone score; VFA = vertebral fracture assessment; WHO = World Health Organization.

Adult spinal deformity and its relationship with height loss: a 34-year longitudinal cohort study

Background

Age-related height loss is a normal physical change that occurs in all individuals over 50 years of age. Although many epidemiological studies on height loss have been conducted worldwide, none have been long-term longitudinal epidemiological studies spanning over 30 years. This study was designed to investigate changes in adult spinal deformity and examine the relationship between adult spinal deformity and height loss.

Methods

Fifty-three local healthy subjects (32 men, 21 women) from Furano, Hokkaido, Japan, volunteered for this longitudinal cohort study. Their heights were measured in 1983 and again in 2017. Spino-pelvic parameters were compared between measurements obtained in 1983 and 2017. Individuals with height loss were then divided into two groups, those with degenerative spondylosis and those with degenerative lumbar scoliosis, and different characteristics were compared between the two groups.

Results

The mean age of the subjects was 44.4 (31–55) years at baseline and 78.6 (65–89) years at the final follow-up. The mean height was 157.4 cm at baseline and 153.6 cm at the final follow-up, with a mean height loss of 3.8 cm over 34.2 years. All parameters except for thoracic kyphosis were significantly different between measurements taken in 1983 and 2017 (p < 0.05). Height loss in both sexes was related to changes in pelvic parameters including pelvic incidence-lumbar lordosis (R = 0.460 p = 0.008 in men, R = 0.553 p = 0.012 in women), pelvic tilt (R = 0.374 p = 0.035 in men, R = 0.540 p = 0.014 in women), and sagittal vertical axis (R = 0.535 p = 0.002 in men, R = 0.527 p = 0.017 in women). Greater height loss was more commonly seen in women (p = 0.001) and in patients with degenerative lumbar scoliosis (p = 0.02).

Conclusions

This longitudinal study revealed that height loss is more commonly observed in women and is associated with adult spinal deformity and degenerative lumbar scoliosis. Height loss is a normal physical change with aging, but excessive height loss is due to spinal kyphosis and scoliosis leading to spinal malalignment. Our findings suggest that height loss might be an early physical symptom for spinal malalignment.

Measured height loss predicts incident clinical fractures independently from FRAX: a registry-based cohort study

During median follow-up 6.0 years in 11,495 individuals, prior absolute and annualized measured height loss was significantly greater in those with subsequent incident fracture compared with those without incident fracture.

PURPOSE

FRAX® accepts baseline height and weight as input variables, but does not consider change in these parameters over time.

AIM

To evaluate the association between measured height or weight loss on subsequent fracture risk adjusted for FRAX scores, risk factors, and competing mortality.

METHODS

Using a dual-energy x-ray absorptiometry (DXA) registry for the Province of Manitoba, Canada, we identified women and men age 40 years or older with height and weight measured at the time of two DXA scans. Cox regression analyses were performed to test for a covariate-adjusted association between prior height and weight loss with incident fractures occurring after the second scan using linked population-based healthcare data.

RESULTS

The study population consisted of 11,495 individuals (average age 68.0 ± 9.9 years, 94.6% women). During median follow-up 6.0 years, records demonstrated incident major osteoporotic fracture (MOF) in 869 individuals, hip fractures in 265, clinical vertebral fractures in 207, and any fracture in 1203. Prior height loss was significantly greater in individuals with fracture compared with those without fracture, regardless of fracture site. Mortality was greater in those with prior height loss (HR per SD 1.11, 95% CI 1.06-1.17) or weight loss (HR per SD 1.26, 95% CI 1.19-1.32). Each SD in height loss was associated with increased fracture risk (MOF 12-17%, hip 8-19%, clinical vertebral 28-37%, any fracture 14-19%). Prior weight loss was associated with 21-30% increased risk for hip fracture, but did not increase risk for other fractures. Height loss of 3.0 cm or greater more than doubled the risk for subsequent fracture.

CONCLUSIONS

Prior height loss is associated with a small but significant increase in risk of incident fracture at all skeletal sites independent of other clinical risk factors and competing mortality as considered by FRAX. Prior weight loss only increases risk for subsequent hip fracture.

The Accuracy of Prevalent Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches

Due to concerns about cumulative radiation exposure in the pediatric population, it is not standard practice to perform spine radiographs in most conditions that predispose to vertebral fracture (VF). In this study we examined the accuracy of two clinical predictors, back pain and lumbar spine bone mineral density (LS BMD), to derive four case-finding paradigms for detection of prevalent VF (PVF). Subjects were 400 children at risk for PVF (leukemia 186, rheumatic disorders 135, nephrotic syndrome 79). Back pain was assessed by patient report, LS BMD was measured by dual-energy X-ray absorptiometry, and PVF were quantified on spine radiographs using the modified Genant semiquantitative method. Forty-four patients (11.0%) had PVF. Logistic regression analysis between LS BMD and PVF produced an odds ratio (OR) of 1.9 (95% confidence interval [CI], 1.5 to 2.5) per reduction in Z-score unit, an area under the receiver operating characteristic curve of 0.70 (95% CI, 0.60 to 0.79), and an optimal BMD Z-score cutoff of -1.6. Case identification using either low BMD alone (Z-score < -1.6) or back pain alone gave similar results for sensitivity (55%, 52%, respectively), specificity (78%, 81%, respectively), positive predictive value (PPV; 24%, 25%, respectively), and negative predictive value (NPV; 93%, 93%, respectively). The paradigm using low BMD plus back pain produced lower sensitivity (32%), higher specificity (96%), higher PPV (47%), and similar NPV (92%). The approach using low BMD or back pain had the highest sensitivity (75%), lowest specificity (64%), lowest PPV (20%), and highest NPV (95%). All paradigms had increased sensitivities for higher fracture grades. Our results show that BMD and back pain history can be used to identify children with the highest risk of PVF so that radiography can be used judiciously. The specific paradigm to be applied will depend on the expected PVF rate and the clinical approach to the use of radiography. © 2019 American Society for Bone and Mineral Research.

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.

Impact of Vertebral Fractures and Glucocorticoid Exposure on Height Deficits in Children During Treatment of Leukemia

OBJECTIVE

To assess the effect of vertebral fractures (VF) and glucocorticoid (GC) exposure on height deficits in children during treatment of acute lymphoblastic leukemia (ALL).

METHODS

Children with ALL treated without cranial radiation therapy (n = 160; median age, 5.1 years; 58.1% male) were followed prospectively for 6 years. Spinal deformity index (SDI) was used to quantify VF status.

RESULTS

Baseline height z score ± SD was 0.3 ± 1.2. It fell by 0.5 ± 0.4 in the first 6 months for boys and by 0.4 ± 0.4 in the first 12 months for girls (P < 0.01 for both) and then subsequently recovered. The prevalence of VF peaked at 1 year (17.6%). Among those with VF, median SDI rose from 2 [interquartile range (IQR): 1, 7] at baseline to 8 (IQR: 1, 8) at 1 year. A mixed model for repeated measures showed that height z score declined by 0.13 (95% CI: 0.02 to 0.24; P = 0.02) for each 5-unit increase in SDI during the previous 12 months. Every 10 mg/m2 increase in average daily GC dose (prednisone equivalent) in the previous 12 months was associated with a height z score decrement of 0.26 (95% CI: 0.20 to 0.32; P < 0.01).

CONCLUSIONS

GC likely plays a major role in the observed height decline during therapy for ALL. Because only a minority of children had VF, fractures could not have contributed significantly to the height deficit in the entire cohort but may have been important among the subset with VF.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS - 2016

ABBREVIATIONS

AACE = American Association of Clinical Endocrinologists AFF = atypical femur fracture ASBMR = American Society for Bone and Mineral Research BEL = best evidence level BMD = bone mineral density BTM = bone turnover marker CBC = complete blood count CI = confidence interval DXA = dual-energy X-ray absorptiometry EL = evidence level FDA = U.S. Food and Drug Administration FLEX = Fracture Intervention Trial (FIT) Long-term Extension FRAX_® = Fracture Risk Assessment Tool GFR = glomerular filtration rate GI = gastrointestinal HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly IOF = International Osteoporosis Foundation ISCD = International Society for Clinical Densitometry IU = international units IV = intravenous LSC = least significant change NBHA = National Bone Health Alliance NOF = National Osteoporosis Foundation 25(OH)D = 25-hydroxy vitamin D ONJ = osteonecrosis of the jaw PINP = serum carboxy-terminal propeptide of type I collagen PTH = parathyroid hormone R = recommendation RANK = receptor activator of nuclear factor kappa-B RANKL = receptor activator of nuclear factor kappa-B ligand RCT = randomized controlled trial RR = relative risk S-CTX = serum C-terminal telopeptide SQ = subcutaneous VFA = vertebral fracture assessment WHO = World Health Organization.

Is Retinal Microvascular Abnormalities an Independent Risk Factor of Vertebral Fractures? A Prospective Study From a Chinese Population

Low bone mineral density (BMD) and microvascular diseases (MVD) share various common risk factors; however, whether MVD is an independent risk factor of vertebral fractures is incompletely understood. The aim of this study is to clarify whether MVD is an independent risk factor of vertebral fractures. In this prospective study, calcaneal BMD and retinal microvascular abnormalities were assessed at baseline from June 2011 to January 2012. A total of 2176 premenopausal women, 2633 postmenopausal women, 2998 men aged <65 years, and 737 men aged ≥65 were included. Then with/without retinal microvascular abnormalities cohorts were followed for an average of 2.93 years to find out the relationship between MVD and vertebral fractures. At the baseline, after full adjustment, retinal microvascular abnormalities were related to risk of low BMD only in men aged ≥65 years (odds ratio [OR] = 2.506; 95% confidence interval [CI] 1.454–4.321; p = 0.001). After follow‐up of 2.93 years, retinal microvascular abnormalities were related to risk of vertebral fractures in men aged ≥65 years (OR = 2.475; 95% CI 1.085–5.646; p = 0.031) when adjustment for confounding factors. However, no associations were found between MVD and vertebral fractures in men aged <65 years, premenopausal women, and postmenopausal women. When stratified by diabetes, in the without‐diabetes group, the men with retinal microvascular abnormalities had higher risk for vertebral fractures than without retinopathy (OR = 2.194; 95% CI 1.097–4.389; p = 0.026); however, the difference was not found in women. In the diabetes group, there were no significant differences of risk for vertebral fractures between those with retinal microvascular abnormalities and those without both in men and women. Stratified by hypertension, the men with retinopathy had higher risk for vertebral fractures than those without among the hypertension group (OR = 2.034; 95% CI 1.163–3.559; p = 0.013), but a difference was not found among women. In the without‐hypertension group, no relation was found between MVD and fracture both in men and women. In conclusion, MVD is an independent risk factor of vertebral fractures in old men. © 2017 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Risk factors for 5-year prospective height loss among postmenopausal women

OBJECTIVE

Height loss is common in older women and has been associated with increased morbidity and mortality. In this study, we identified factors that could predict prospective height loss in postmenopausal women.

METHODS

Height was measured in 1,024 postmenopausal women, enrolled in the Buffalo Osteoporosis and Periodontal Disease Study, at baseline and 5 years later using a fixed stadiometer. Demographics, lifestyle, medical history, and medication use were assessed at baseline. Stepwise logistic regression was used to identify factors that are associated with marked height loss of ≥1 inch. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for each predictor. Receiver-operating characteristic (ROC) curve was performed to determine the discriminatory ability of the prediction model.

RESULTS

The mean loss of height was 0.4 (SD 0.7) inches. Age (OR 1.11, 95% CI 1.06-1.16), weight (OR 1.05, 95% CI 1.03-1.07), use of oral corticosteroids (OR 4.96, 95% CI 1.25-19.72), and strenuous exercise at age 18 ≥ three times per week (OR 0.55, 95% CI 0.31-0.98) were significantly associated with marked height loss in the multivariable-adjusted model. The area under the ROC curve is 72.1%. Addition of bone mineral density measures did not improve the discriminatory ability of the prediction model.

CONCLUSIONS

This set of available variables may be useful in predicting the 5-year risk of height loss of 1 inch or more in postmenopausal women. These findings may help to target older women at risk of height loss who may benefit most from prevention strategies for fracture and mortality.

Effects of discontinuing oral bisphosphonate treatments for postmenopausal osteoporosis on bone turnover markers and bone density

The antiresorptive potency varies between different bisphosphonates. We investigated the effect of stopping oral bisphosphonate treatment for postmenopausal osteoporosis (ibandronate, alendronate, risedronate) on BTMs and BMD. After stopping treatment, all three groups showed an increase in BTMs and a decrease in hip BMD; however, none returned to pre-treatment baseline values.

INTRODUCTION

Bisphosphonates (BPs) continue to suppress bone turnover markers (BTMs) after treatment has stopped, leading to the suggestion that a pause in treatment could be considered for low-risk patients. Indirect comparisons suggest that after cessation of treatment, the effects on bone may differ between drugs. We investigated the effects of stopping oral BP treatments for postmenopausal osteoporosis on BTMs and bone mineral density (BMD).

METHODS

We studied postmenopausal osteoporotic women who had previously taken part in a 2-year randomised study of three oral BPs (ibandronate, alendronate, or risedronate). At the end of the study, women with hip BMD T-score > - 2.5 and considered clinically appropriate to discontinue treatment were invited to participate in a further 2-year observational study. Biochemical response was assessed using BTMs, and BMD was measured by dual-energy X-ray absorptiometry.

RESULTS

All BTMs increased after treatment withdrawal but remained below the pre-treatment baseline with less suppression of BTMs for the risedronate group compared to alendronate and ibandronate up to 48 weeks. There was no difference between the BP groups 96 weeks after stopping treatment. The change in BMD during the 96 weeks after stopping treatment was - 1.6% (95% CI - 1.9 to - 1.2, P < 0.001) for the total hip and - 0.6% (95% CI - 1.1 to - 0.2, P = 0.17) at the lumbar spine with no difference between the three BP groups (P = 0.85 and P = 0.48, respectively).

CONCLUSION

For all treatment groups, there was an increase in BTMs and a decrease in hip BMD after stopping BPs for 2 years; however, none returned to pre-treatment baseline values.

2018 update of French recommendations on the management of postmenopausal osteoporosis

OBJECTIVES

To update the 2012 recommendations on pharmacotherapy for postmenopausal osteoporosis, under the aegis of the Bone Task Force of the French Society for Rheumatology (SFR) and of the Osteoporosis Research and Information Group (GRIO), in collaboration with scientific societies (Collège national des généralistes enseignants, Collège national des gynécologues et obstétriciens français, Fédération nationale des collèges de gynécologie médicale, Groupe d'étude de la ménopause et du vieillissement hormonal, Société française de chirurgie orthopédique, Société française d'endocrinologie, and Société française de gériatrie et de gérontologie).

METHODS

Updated recommendations were developed by a task force whose members represented the medical specialties involved in the management of postmenopausal osteoporosis. The update was based on a literature review and developed using the method advocated by the French National Authority for Health (HAS).

DISCUSSION AND CONCLUSION

The updated recommendations place strong emphasis on the treatment of women with severe fractures, in whom the use of osteoporosis medications is recommended. All the available osteoporosis medications are suitable in patients with severe fractures; zoledronic acid deserves preference as the fist-line drug after a hip fracture. In patients with or without non-severe fractures, the decision to use osteoporosis medications is based on bone mineral density values and in challenging cases, on probabilities supplied by prediction tools such as FRAX^®. All osteoporosis medications are suitable; raloxifene should be reserved for patients at low risk for peripheral fractures. The fracture risk should be reevaluated every 2 to 3 years to decide on the best follow-up treatment. These updated recommendations discuss the selection of first-line osteoporosis medications and treatment sequences.

[Osteoporosis: Current state of the art]

As of now, osteoporosis (OP) is one of the most important sociomedical problems because of its high prevalence and resultant disability, as well as significant mortality attributable to complications. The current strategy for providing care for patients of OP is its early diagnosis, by determining the high risk of fractures, and early pathogenetic treatment. The article gives an update on the epidemiology, risk factors, diagnosis, and treatment of OP.

Inaccurate self-report of height and its impact on misclassification of body mass index in postmenopausal women

OBJECTIVE

Self-reported height is commonly used in population obesity research. Evidence has also shown a positive association between depression and obesity. We examined the extent of height misreporting and its impact on body mass index (BMI) calculations and classification, and explored whether depression is associated with height misreporting.

METHODS

The Buffalo Osteoporosis and Periodontal Disease Follow-up Study enrolled 1,015 postmenopausal women between 2002 and 2006. Participants self-reported their height on a questionnaire before stadiometer measurement at the clinical visit. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. Odds ratios and 95% CI for association between depression and height misreporting were estimated using logistic regression.

RESULTS

Overall, 446 women (43.9%) misreported height by greater than 1/2 inch, of which 296 (29.2%) underestimated and 150 (14.8%) overestimated their height. Height misreporting influenced BMI calculations by ≥1 unit in 12% of women, and influenced classification into WHO BMI categories in 8% of women. After adjusting for age, race, education, and measured BMI, women with significant depressive symptoms were more likely to misreport their height (odds ratio = 1.65, 95% CI, 1.04-2.61).

CONCLUSIONS

Height misreporting was common in older women and significantly influenced BMI calculations and classification. Obtaining objective data is thus important for studies investigating obesity-disease associations in this population, especially in those with significant depressive symptoms.

Bone health among older adults in Taiwan

BACKGROUND AND PURPOSE

There has been much discussion about the risk factors for osteoporosis, but studies involving elderly population in Taiwan are minimal. We aimed to describe variables related to osteoporosis among community dwelling older people in Taiwan.

METHODS

This is a cross-sectional study. The 671 participants were randomly selected from 3680 examinees of the annual Senior Citizens Health Examination in year 2010. Participants were interviewed with a detailed questionnaire, and 91 of them were invited for dual-energy X-ray absorptiometry (DXA). Predictor variables included age, gender and clinical risk factors for osteoporosis. The main outcome was osteoporosis confirmed by DXA.

RESULTS

The mean age of the participants was 75.7±6.4years old. Overall, the most prevalent variables for osteoporosis were height loss in adulthood (41.0%), lack of dairy products or calcium supplements (32.0%) and insufficient physical activity (10.4%). In multivariate models, we found that underweight (OR=9.80) and lack of dairy products/calcium supplements (OR=3.68) were the main variables for osteoporosis. In the subgroup analysis involving only women, underweight (OR=14.60) was the main variable.

DISCUSSION

Among community-dwelling older people in Taiwan, osteoporosis was mainly associated with underweight and lack of dairy products or calcium supplements.

CONCLUSION

We suggest using the key questions of underweight and dietary pattern in clinical settings to identify high risk people who are candidates for further BMD exam.

Goal-Directed Treatment for Osteoporosis: A Progress Report From the ASBMR-NOF Working Group on Goal-Directed Treatment for Osteoporosis

The American Society for Bone and Mineral Research and the United States National Osteoporosis Foundation (NOF) formed a working group to develop principles of goal-directed treatment and identify gaps that need to be filled to implement this approach. With goal-directed treatment, a treatment goal would first be established and choice of treatment determined by the probability of achieving that goal. Goals of treatment would be freedom from fracture, a T-score > -2.5, which is above the NOF threshold for initiating treatment, or achievement of an estimated risk level below the threshold for initiating treatment. Progress toward reaching the patient's goal would be periodically and systematically assessed by estimating the patient's compliance with treatment, reviewing fracture history, repeating vertebral imaging when indicated, and repeating measurement of bone mineral density (BMD). Using these data, a decision would be made to stop, continue, or change therapy. Some of these approaches can now be applied to clinical practice. However, the application of goal-directed treatment cannot be fully achieved until medications are available that provide greater increases in BMD and greater reduction in fracture risk than those that are currently approved; only then can patients with very high fracture risk and very low BMD achieve such goals. Furthermore, assessing future fracture risk in patients on treatment requires a new assessment tool that accurately captures the change in fracture risk associated with treatment and should also be sensitive to the importance of recent fractures as predictors of imminent fracture risk. Lastly, evidence is needed to confirm that selecting and switching treatments to achieve goals reduces fracture risk more effectively than current standard care. © 2016 American Society for Bone and Mineral Research.

Health-related Quality of Life in Accordance with Fracture History and Comorbidities in Korean Patients with Osteoporosis

Background

The purpose of this study was to explore health-related quality of life (HRQOL) among Korean patients with osteoporosis and to measure the impact of fractures and comorbidity on their quality of life (QOL) using the Korean National Health and Nutrition Examination Survey (KNHANES) data with a nationwide representativeness.

Methods

This study was based on 4-year-data obtained from the KNHANES 2008 to 2011. Osteoporosis was diagnosed in 2,078 survey participants according to their bone mineral density measurements using dual energy X-ray absorptiometry. According to the World Health Organization study group, T-scores at or above -1.0 are considered normal, those between -1.0 and -2.5 as osteopenia, and those at or below -2.5 as osteoporosis The EuroQol five-dimensional questionnaire (EQ-5D) index score was used to assess the QOL.

Results

Of 2,078 patients diagnosed with osteoporosis, fractures were found to occur at 11.02%. Wrist fracture was the most frequent, affecting 4.52% of the patients, with a significantly different prevalence among men and women (P<0.001). The overall EQ-5D index score was 0.84±0.01 among patients with osteoporosis. With the exception of cancer, the EQ-5D index score were significantly lower for those having osteoarthritis, rheumatoid arthritis, hypertension, diabetes, chronic obstructive pulmonary disease and cardiovascular events compared to those without the related diseases.

Conclusions

We found that low health utility was associated with previous spine fracture and comorbidities in patients with osteoporosis. In particular, the number of fracture experiences greatly deteriorated the HRQOL in patients with osteoporosis. Thus, prevention of secondary fractures and chronic care model for comorbidities should be a priority for osteoporosis management in order to improve HRQOL.

Associations of self-reported height loss and kyphosis with vertebral fractures in Japanese women 60 years and older: a cross-sectional survey

Some vertebral fractures come to clinical attention but most do not. This cross-sectional survey aimed to clarify the associations of self-reported height loss and kyphosis with vertebral fractures. We enrolled 407 women aged 60-92 years who visited our orthopaedic clinic between June and August 2014 in our study. Inclusion criteria were lateral radiography followed by completion of a structured questionnaire in this study. The primary outcome was vertebral fracture diagnosed on lateral radiography and graded using a semiquantitative grading method, from SQ0 (normal) to SQ3 (severe). Self-reported kyphosis was defined as none, mild to moderate, severe. Self-reported height loss was defined as <4 cm or ≥4 cm. Number of SQ1 fracture was associated only with kyphosis. Self-reported severe kyphosis was significantly associated with increased numbers of ≥SQ2 vertebral fractures (p = 0.007). Height loss ≥4 cm was significantly associated with increased ≥SQ2 grade fractures (p < 0.001). Odds ratios (ORs) for fractures associated with mild-to-moderate and severe kyphosis were 2.1 [95% confidence interval 1.4 to 3.3) and 4.2 (1.8 to 9.5), respectively. OR for fractures associated with height loss ≥4 cm was 2.3 (1.4 to 3.7). Self-reported kyphosis may be useful for identifying Japanese women aged ≥60 years who have undetected vertebral fractures.

Association of age-dependent height and bone mineral density decline with increased arterial stiffness and rate of fractures in hypertensive individuals

OBJECTIVE

Hypertension and osteoporosis are age-related health risks differentially expressed in men and women. Here we have analysed their prevalence in a randomly selected cross-sectional cohort [CARTaGENE (CaG) of Quebec, Canada and explored their existing relationships along with height, arterial stiffness and bone fractures.

METHODS

The principal cohort CaG included 20 007 individuals of age 40-70 years. Participants were subjected to an extensive phenotyping and a questionnaire of medical history and habits.

RESULTS

We determined the differences in height of participants and their relation to hypertension status and sex in this cohort and validated it in two other cohorts (The Canadian Heart Health Study and a family cohort from the Saguenay Lac Saint-Jean, a region of Quebec). In all three cohorts, we found that at younger age individuals with hypertension are taller than normotensive individuals, but they have a shorter stature at an older age compared with normotensive individuals. In CaG, we observed that hypertension, low bone mineral density (BMD) and arterial stiffness are strongly associated with height when adjusted for antihypertensive medications (P < 0.0001). Fractures are the net outcome of low BMD, and a significant association is observed (odds ratio = 2.34, confidence interval = 2.12-2.57); this relation was stronger in hypertensive individuals compared with normotensive individuals particularly in younger hypertensive individuals. In addition, we observed that increased arterial stiffness was significantly correlated with a low BMD in both men and women at all ages.

CONCLUSION

Shorter stature in elderly, low BMD and fractures correlated with increased arterial stiffness and hypertension. We propose that hypertension and osteoporosis share components of accelerated aging.

COPD and osteoporosis: links, risks, and treatment challenges

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory airway disease associated with various systemic comorbidities including osteoporosis. Osteoporosis and its related fractures are common and have significant impacts on quality of life and even respiratory function in patients with COPD. COPD-associated osteoporosis is however extremely undertreated. Recent studies have suggested that both decreased bone mineral density (BMD) and impaired bone quality contribute to bone fragility, causing fractures in COPD patients. Various clinical risk factors of osteoporosis in COPD patients, including older age, emaciation, physical inactivity, and vitamin D deficiency, have also been described. It is critically important for pulmonologists to be aware of the high prevalence of osteoporosis in COPD patients and evaluate them for such fracture risks. Routine screening for osteoporosis will enable physicians to diagnose COPD patients with comorbid osteoporosis at an early stage and give them appropriate treatment to prevent fracture, which may lead to improved quality of life as well as better long-term prognosis.

Vertebral Fractures: Clinical Importance and Management

Vertebral fractures are common and can result in acute and chronic pain, decreases in quality of life, and diminished lifespan. The identification of vertebral fractures is important because they are robust predictors of future fractures. The majority of vertebral fractures do not come to clinical attention. Numerous modalities exist for visualizing suspected vertebral fracture. Although differing definitions of vertebral fracture may present challenges in comparing data between different investigations, at least 1 in 5 men and women aged >50 years have one or more vertebral fractures. There is clinical guidance to target spine imaging to individuals with a high probability of vertebral fracture. Radiology reports of vertebral fracture need to clearly state that the patient has a "fracture," with further pertinent details such as the number, recency, and severity of vertebral fracture, each of which is associated with risk of future fractures. Patients with vertebral fracture should be considered for antifracture therapy. Physical and pharmacologic modalities of pain control and exercises or physiotherapy to maintain spinal movement and strength are important components in the care of vertebral fracture patients.

Clinical Management of Vertebral Compression Fractures

Vertebral compression fractures (VCF's) are the most common form of osteoporotic fractures. Whether symptomatic or asymptomatic, they both represent a high risk for not only vertebral but also nonvertebral fractures in untreated populations. This high risk of future fracture after a VCF is independent of the T-score because bone strength is a combination of bone mineral density and bone quality. VCFs are the single greatest risk for future fractures at all other skeletal sites in untreated populations, including hip fractures. They are often unrecognized despite their exceptionally high prevalence in all genders and most ethnic groups as age increases. This article highlights some of the key messages about VCF's, and how assessment for their presence and then management will reduce the risk of all osteoporotic fractures.

Recommendations for evaluation and management of bone disease in HIV

Thirty-four human immunodeficiency virus (HIV) specialists from 16 countries contributed to this project, whose primary aim was to provide guidance on the screening, diagnosis, and monitoring of bone disease in HIV-infected patients. Four clinically important questions in bone disease management were identified, and recommendations, based on literature review and expert opinion, were agreed upon. Risk of fragility fracture should be assessed primarily using the Fracture Risk Assessment Tool (FRAX), without dual-energy X-ray absorptiometry (DXA), in all HIV-infected men aged 40-49 years and HIV-infected premenopausal women aged ≥40 years. DXA should be performed in men aged ≥50 years, postmenopausal women, patients with a history of fragility fracture, patients receiving chronic glucocorticoid treatment, and patients at high risk of falls. In resource-limited settings, FRAX without bone mineral density can be substituted for DXA. Guidelines for antiretroviral therapy should be followed; adjustment should avoid tenofovir disoproxil fumarate or boosted protease inhibitors in at-risk patients. Dietary and lifestyle management strategies for high-risk patients should be employed and antiosteoporosis treatment initiated.

Patient perceptions of provider barriers to post-fracture secondary prevention

We examined patients' experiences regarding bone mineral density (BMD) testing and bone health treatment after being screened through Ontario's Fracture Clinic Screening Program. Provider-level barriers to testing and treatment appeared to be as significant as patient-level barriers and potentially had more of an impact on treatment than on testing.

INTRODUCTION

Post-fracture secondary prevention programs have had modest effects on bone densitometry rates and osteoporosis (OP) treatment initiation. Few studies have examined in depth the reasons that patients choose to seek or avoid investigation and treatment after screening through such a program. Our purpose was to examine patients' experiences regarding bone mineral density (BMD) testing and bone health treatment after screening through Ontario's Fracture Clinic Screening Program (FCSP).

METHODS

We conducted a prospective qualitative study in fragility fracture patients screened through one site of the FCSP. Eligible patients not on antiresorptive medication at the time of fracture were assessed by an osteoporosis screening coordinator and advised to follow up with their primary care physician for a BMD test and appropriate treatment. Participants were interviewed within 6, and within 18, months of their clinic visit. Fracture risk was assessed by the study team. Interviews were transcribed verbatim and analyzed by two researchers.

RESULTS

We conducted 51 interviews with 25 patients (22 females, 3 males) aged 50-79 years old, of whom 8 were deemed high risk for future fracture. Eighteen participants had a BMD test between baseline and follow-up and three reported receiving a prescription for pharmacotherapy. We categorized 21 participants as experiencing at least one barrier to BMD testing and appropriate treatment including health care providers telling participants that the fracture was not a fragility fracture, using participants' appearance/demographic information and X-rays to judge bone density, telling participants that a BMD test was not appropriate, failing to discuss fracture risk status, and giving unclear or incorrect information about treatment.

CONCLUSION

We identified modifiable barriers to post-fracture secondary prevention from the patient's perspective. Provider-level barriers appeare to be as significant as patient-level barriers and potentially had more of an impact on treatment than on BMD testing.

Radiation-free spinometry adds to the predictive power of historical height loss in clinical vertebral fracture assessment

After introducing radiation-free spinometry as a diagnostic tool to predict prevalent vertebral fractures, its validity and comparison with established tools such as historical height loss (HHL) was missing. This study shows that radiation-free spinometry is valid and its application adds predictive power to the ability of HHL to assess presence of vertebral fractures.

INTRODUCTION

Recently, radiation-free spinometry was introduced to identify patients with vertebral fractures (VFs). The goals of this study were to validate previous findings and to test the predictive accuracy of radiation-free spinometry compared to the assessment of historical height loss (HHL).

METHODS

We analyzed 304 patients [258 (85%) females (age range, 42-90 years) and 46 males (50-84 years)], including 108 patients with VFs. We performed receiver operator characteristic and net reclassification improvement (NRI) analyses to quantify the predictive power and the added predictive ability of radiation-free spinometry and HHL for VFs.

RESULTS

The estimated odds ratios in the thoracic and the lumbar spine showed no significant differences compared to the previously published, except for the effect of thoracic kyphosis in region "Th12 + L4-5." Radiation-free spinometry and HHL were both moderately accurate to raise suspicion for VFs. According to the NRI, which is defined as the net sum of the predicted risk increase in individuals who have VFs and the predicted net risk decrease for those who have not, we found significant improvements in all regions of interest when HHL and radiation-free spinometry were used in combination (area under the curve (AUC) 0.729-0.788).

CONCLUSION

Our results based on a new data set suggest validity of the prognostic score published previously. In addition, although our findings did not confirm our initial hypothesis that radiation-free spinometry alone performs superior to the assessment of HHL to predict VFs, we showed that radiation-free spinometry still adds predictive power to the ability of HHL to discriminate patients with VFs.

Detective value of historical height loss and current height/knee height ratio for prevalent vertebral fracture in Japanese postmenopausal women

Vertebral fracture (VFx) is associated with various co-morbidities and increased mortality. In this paper, we have studied the detective value of height loss for VFx using two indices; historical height loss (HHL) which is the difference between the maximal height, and the current height (CH), and CH/knee height (KH) ratio. One-hundred and fifty-one postmenopausal women visiting the outpatient clinic of orthopaedics were studied for their CH, self-reported maximal height, KH, and radiographically diagnosed VFx number(s). VFx was present in 41.1 % of the subjects. Multiple regression analyses revealed that the number of prevalent fractures was a significant predictor of HHL and CH/KH ratio. Receiver operator characteristic curve analysis has shown that for HHL, the area under the curve (AUC) with their 95 %CI in the parentheses was 0.84 (0.77, 0.90), 0.88 (0.83, 0.94), and 0.91 (0.86, 0.96) for ≥ 1, ≥ 2, and ≥ 3 fractures, respectively. For the presence of ≥ 1 VFx, the cut-off value was 4.0 cm (specificity 79 %; sensitivity 79 %). Regarding the CH/KH ratio, AUC was 0.73 (0.65, 0.82), 0.85 (0.78, 0.93), and 0.91 (0.86, 0.96) for ≥ 1, ≥ 2, and ≥ 3 fractures, respectively. For the presence of ≥ 1 VFx, the cut-off value was 3.3 (specificity 47 %; sensitivity 91 %). Both cut-off values for HHL and CH/KH ratio had high negative predictivity across the wide range of theoretical VFx prevalence. Thus, HHL and CH/KH were both good detectors of VFx. Our data would be the basis to determine the cut-off value for the screening or case finding of subjects with VFx.

Build better bones with exercise: protocol for a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in women with a vertebral fracture

BACKGROUND

Our goal is to conduct a multicenter randomized controlled trial (RCT) to investigate whether exercise can reduce incident fractures compared with no intervention among women aged ≥65 years with a vertebral fracture.

OBJECTIVES

This pilot study will determine the feasibility of recruitment, retention, and adherence for the proposed trial.

DESIGN

The proposed RCT will be a pilot feasibility study with 1:1 randomization to exercise or attentional control groups.

SETTING

Five Canadian sites (1 community hospital partnered with an academic center and 4 academic hospitals or centers affiliated with an academic center) and 2 Australian centers (1 academic hospital and 1 center for community primary care, geriatric, and rehabilitation services).

PARTICIPANTS

One hundred sixty women aged ≥65 years with vertebral fracture at 5 Canadian and 2 Australian centers will be recruited.

INTERVENTION

The Build Better Bones With Exercise (B3E) intervention includes exercise and behavioral counseling, delivered by a physical therapist in 6 home visits over 8 months, and monthly calls; participants are to exercise ≥3 times weekly. Controls will receive equal attention.

MEASUREMENTS

Primary outcomes will include recruitment, retention, and adherence. Adherence to exercise will be assessed via calendar diary. Secondary outcomes will include physical function (lower extremity strength, mobility, and balance), posture, and falls. Additional secondary outcomes will include quality of life, pain, fall self-efficacy, behavior change variables, intervention cost, fractures, and adverse events. Analyses of feasibility objectives will be descriptive or based on estimates with 95% confidence intervals, where feasibility will be assessed relative to a priori criteria. Differences in secondary outcomes will be evaluated in intention-to-treat analyses via independent Student t tests, chi-square tests, or logistic regression. The Bonferroni method will be used to adjust the level of significance for secondary outcomes so the overall alpha level is .05.

LIMITATIONS

No assessment of bone mineral density will be conducted. The proposed definitive trial will require a large sample size.

CONCLUSIONS

The viability of a large-scale exercise trial in women with vertebral fractures will be evaluated, as well as the effects of a home exercise program on important secondary outcomes.

Knee osteoarthritis is associated with increased prevalence of vertebral fractures despite high systemic bone mineral density: a cross-sectional study in an Asian population

OBJECTIVES

This study aimed to evaluate the relationship between radiographic knee osteoarthritis and vertebral fractures (VFs) in an Asian population.

METHODS

This cross-sectional study involved data from 1,829 participants of the Fifth Korean National Health and Nutrition Examination Survey. Radiographic knee osteoarthritis was defined as Kellgren-Lawrence (KL) grades ≥ 2. Prevalent VF was defined as a loss of ≥ 4 cm of height from the peak height. BMD was measured using dual-energy X-ray absorptiometry, in the lumbar spine and femoral neck.

RESULTS

In both sexes, the prevalence of VFs increased with age, and was higher in the knee osteoarthritis group than in the control group (in men 13.2 % in osteoarthritis group and 7.9 % in control group; in women 27.7 % in osteoarthritis group and 14.7 % in control group). Age-adjusted BMD at the lumbar spine and femoral neck was significantly higher in the knee osteoarthritis group. In multivariable analysis, KL grade 4 was significantly associated with vertebral fractures in men. In women, there was a significant trend for a positive association between KL grades and vertebral fractures.

CONCLUSIONS

Despite high systemic BMD, knee osteoarthritis was positively associated with VFs. These results suggest that bone quality, and consequently bone strength, may be decreased at the systemic level in knee osteoarthritis.

Risks and benefits of percutaneous vertebroplasty or kyphoplasty in the management of osteoporotic vertebral fractures

Vertebral fracture (VF) is the most common osteoporotic fracture and is associated with high morbidity and mortality. Conservative treatment combining antalgic agents and rest is usually recommended for symptomatic VFs. The aim of this paper is to review the randomized controlled trials comparing the efficacy and safety of percutaneous vertebroplasty (VP) and percutaneous balloon kyphoplasty (KP) versus conservative treatment. VP and KP procedures are associated with an acceptable general safety. Although the case series investigating VP/KP have all shown an outstanding analgesic benefit, randomized controlled studies are rare and have yielded contradictory results. In several of these studies, a short-term analgesic benefit was observed, except in the prospective randomized sham-controlled studies. A long-term analgesic and functional benefit has rarely been noted. Several recent studies have shown that both VP and KP are associated with an increased risk of new VFs. These fractures are mostly VFs adjacent to the procedure, and they occur within a shorter time period than VFs in other locations. The main risk factors include the number of preexisting VFs, the number of VPs/KPs performed, age, decreased bone mineral density, and intradiscal cement leakage. It is therefore important to involve the patients to whom VP/KP is being proposed in the decision-making process. It is also essential to rapidly initiate a specific osteoporosis therapy when a VF occurs (ideally a bone anabolic treatment) so as to reduce the risk of fracture. Randomized controlled studies are necessary in order to better define the profile of patients who likely benefit the most from VP/KP.

The association between higher serum ferritin level and lower bone mineral density is prominent in women ≥45 years of age (KNHANES 2008-2010)

SUMMARY

Data gathered from a nationally representative cohort demonstrate that higher serum ferritin levels are significantly associated with lower bone mass at various skeletal sites and the increased prevalence of osteoporosis and fractures, especially in women ≥45 years of age.

INTRODUCTION

Despite extensive in vitro and in vivo studies showing the detrimental effects of iron on bone metabolism, the clinical studies relating to osteoporosis-related phenotypes have not been evaluated extensively. In the present study, we investigated and compared the association between serum ferritin and bone mineral density (BMD), depending on the stratified age groups in both genders.

METHODS

This is a population-based, cross-sectional study from the Korea National Health and Nutrition Examination Surveys, including 14,017 Koreans (6,817 men and 7,200 women) aged 10-80 years. BMD was measured using dual X-ray absorptiometry, and osteoporosis was diagnosed by the World Health Organization definition.

RESULTS

Initially, we divided the subjects into three age groups, based on the patterns of age-related BMD changes in this national cohort (i.e., ≤24, 25-44, and ≥45 years old). Serum ferritin concentrations were inversely associated with BMD values at all measured sites after adjustment for confounders, only in women ≥45 years of age (P = 0.041 to <0.001). Furthermore, when we divided these women into serum ferritin quartiles, the odds for prevalent osteoporosis and fractures were 1.55-fold (95 % CI = 1.09-2.23) and 1.52-fold (95 % CI = 1.02-2.27) higher, respectively, in subjects in the highest quartile compared with those in the lowest quartile.

CONCLUSIONS

These results provide the first clinical evidence that the associations between serum ferritin level and bone parameters could be the most prominent in women ≥45 years of age.

Influence of non-traumatic thoracic and lumbar vertebral fractures on sagittal spine alignment assessed by radiation-free spinometry

Due to missing indications for specific diagnostics, the majority of non-symptomatic vertebral fractures are not diagnosed. This study shows the ability of radiation-free spinometry to assess sagittal spine parameters to raise suspicion for new non-traumatic thoracic and lumbar vertebral fractures and indicate specific diagnostics.

INTRODUCTION

The primary aim of this study was to investigate the accuracy of radiation-free spinometry to predict new non-traumatic vertebral fractures (VF) by the assessment of thoracic kyphosis (TK), lumbar lordosis (LL), and trunk inclination.

METHODS

Three hundred sixty-one patients (278 females and 83 males; age, 67.0 ± 8.6 years) were enrolled. In 86 women and 24 men, at least one non-traumatic VF was confirmed by radiography, MRI, and/or CT. Spinometry (video rasterstereography) was used to assess TK, LL, and trunk inclination. Receiver operating characteristic (ROC) and multivariate logistic regression analyses were performed to test the influence of age, sex, number, location, and grade of fractures on sagittal spine alignment.

RESULTS

TK, LL, and trunk inclination were associated with advancing age (p < 0.05). Patients with prevalent thoracic and lumbar VFs showed increased TK (p < 0.001), decreased LL (p < 0.001), and increased trunk inclination (p < 0.001) in comparison to patients without VFs. ROC analysis revealed that the combination of TK and LL presented with the best predictive accuracy to raise suspicion for new grade 2 or grade 3 VFs in the thoracic and the lumbar spine (AUC, 0.752-0.771). Odds ratio (OR) showed an increased risk for VFs with increased TK (OR, 1.05-1.11; p < 0.001) and LL (1.05-1.07; p < 0.001) in specified regions of interest. A TK <50° (sensitivity, 88-100 %; specificity, 23-25 %) and LL (78-92 %; 24-27 %) were considered as appropriate cutoffs for future screening.

CONCLUSION

Spinometry showed better predictive accuracy than historical height loss. Severe changes of TK and LL may help to raise suspicion of new VFs radiation-free and indicate proper diagnostics, such as radiographs, MRI, or CT.