1
|
Praveen AD, Sollmann N, Baum T, Ferguson SJ, Benedikt H. CT image-based biomarkers for opportunistic screening of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 2024; 35:971-996. [PMID: 38353706 PMCID: PMC11136833 DOI: 10.1007/s00198-024-07029-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 01/19/2024] [Indexed: 05/30/2024]
Abstract
The use of opportunistic computed tomography (CT) image-based biomarkers may be a low-cost strategy for screening older individuals at high risk for osteoporotic fractures and populations that are not sufficiently targeted. This review aimed to assess the discriminative ability of image-based biomarkers derived from existing clinical routine CT scans for hip, vertebral, and major osteoporotic fracture prediction. A systematic search in PubMed MEDLINE, Embase, Cochrane, and Web of Science was conducted from the earliest indexing date until July 2023. The evaluation of study quality was carried out using a modified Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) checklist. The primary outcome of interest was the area under the curve (AUC) and its corresponding 95% confidence intervals (CIs) obtained for four main categories of biomarkers: areal bone mineral density (BMD), image attenuation, volumetric BMD, and finite element (FE)-derived biomarkers. The meta-analyses were performed using random effects models. Sixty-one studies were included in this review, among which 35 were synthesized in a meta-analysis and the remaining articles were qualitatively synthesized. In comparison to the pooled AUC of areal BMD (0.73 [95% CI 0.71-0.75]), the pooled AUC values for predicting osteoporotic fractures for FE-derived parameters (0.77 [95% CI 0.72-0.81]; p < 0.01) and volumetric BMD (0.76 [95% CI 0.71-0.81]; p < 0.01) were significantly higher, but there was no significant difference with the pooled AUC for image attenuation (0.73 [95% CI 0.66-0.79]; p = 0.93). Compared to areal BMD, volumetric BMD and FE-derived parameters may provide a significant improvement in the discrimination of osteoporotic fractures using opportunistic CT assessments.
Collapse
Affiliation(s)
- Anitha D Praveen
- Early Detection of Health Risks and Prevention, Future Health Technologies, Singapore-ETH Centre (SEC), Campus for Research Excellence and Technological Enterprise (CREATE), 1 Create Way, CREATE Tower, #06-01, Singapore, 138602, Singapore.
| | - Nico Sollmann
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stephen J Ferguson
- Early Detection of Health Risks and Prevention, Future Health Technologies, Singapore-ETH Centre (SEC), Campus for Research Excellence and Technological Enterprise (CREATE), 1 Create Way, CREATE Tower, #06-01, Singapore, 138602, Singapore
- Institute for Biomechanics, ETH-Zurich, Zurich, Switzerland
| | - Helgason Benedikt
- Early Detection of Health Risks and Prevention, Future Health Technologies, Singapore-ETH Centre (SEC), Campus for Research Excellence and Technological Enterprise (CREATE), 1 Create Way, CREATE Tower, #06-01, Singapore, 138602, Singapore
- Institute for Biomechanics, ETH-Zurich, Zurich, Switzerland
| |
Collapse
|
2
|
Voltan G, Di Giovannantonio G, Carretta G, Vianello S, Contessa C, Veronese N, Brandi ML. A novel case-finding strategy based on artificial intelligence for the systematic identification and management of individuals with osteoporosis or at varying risk of fragility fracture. Arch Osteoporos 2024; 19:45. [PMID: 38816562 DOI: 10.1007/s11657-024-01403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 05/13/2024] [Indexed: 06/01/2024]
Abstract
An artificial intelligence-based case-finding strategy has been developed to systematically identify individuals with osteoporosis or at varying risk of fragility fracture. This strategy has the potential to close the critical care gap in osteoporosis treatment in primary care, thereby lessening the societal burden imposed by fragility fractures. BACKGROUND Osteoporotic fractures represent a major cause of morbidity and, in older adults, a precursor of disability, loss of independence, poor quality of life and premature death. Despite the detrimental health impact, osteoporosis remains largely underdiagnosed and undertreated worldwide. Subjects at risk for osteoporosis-related fractures are identified either via organised screening or case finding. In the absence of a population-based screening policy, subjects at high risk of fragility fractures are opportunistically identified when a fracture occurs or because of other clinical risk factors (CRFs) for osteoporotic fracture and areal bone mineral density (aBMD) measured by dual-energy X-ray absorptiometry (DXA). PURPOSE This paper describes the development of a novel case-finding strategy, named Osteoporosis Diagnostic and Therapeutic Pathway (ODTP), which enables to identify subjects with osteoporosis or at varying risk of fragility fracture. This strategy is based on a specifically designed software tool, named "Bone Fragility Query" (BFQ), which analyses the electronic health record (EHR) databases of General Practitioners (GPs) to systematically identify individuals who should be prescribed DXA-BMD measurement, vertebral fracture assessment (VFA) and anti-osteoporosis medications (AOM). CONCLUSIONS The ODTP through BFQ tool is a feasible, convenient and time-saving osteoporosis model of care for GPs during routine clinical practice. It enables GPs to shift their focus from what to do (clinical guidelines) to how to do it in the primary health care setting. It also allows a systematic approach to primary and secondary prevention of fragility fractures, thereby overcoming clinical inertia and contributing to closing the gap between evidence and practice for the management of osteoporosis in primary care.
Collapse
Affiliation(s)
- Gianpaolo Voltan
- Centre for Metabolic Bone Diseases, Health Authority of Venice Province, Noale, Venice, Italy.
| | | | | | | | | | - Nicola Veronese
- Geriatrics Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Maria Luisa Brandi
- Vita-Salute San Raffaele University, Milan, Italy
- Fragility Fractures Observatory, Florence, Italy
- Italian Bone Diseases Research Foundation, Florence, Italy
| |
Collapse
|
3
|
McCloskey E, Tan ATH, Schini M. Update on fracture risk assessment in osteoporosis. Curr Opin Endocrinol Diabetes Obes 2024:01266029-990000000-00098. [PMID: 38809256 DOI: 10.1097/med.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW The assessment of fracture risk is playing an ever-increasing role in osteoporosis clinical management and informing international guidelines for osteoporosis. FRAX, a fracture risk calculator that provides individualized 10-year probabilities of hip and major osteoporotic fracture, has been widely used since 2008. In this review, we recap the development and limitations of intervention thresholds and the role of absolute fracture risk. RECENT FINDINGS There is an increasing awareness of disparities and inequities in the setting of intervention thresholds in osteoporosis. The limitations of the simple use of prior fracture or the DXA-derived BMD T-score threshold are increasingly being discussed; one solution is to use fracture risk or probabilities in the setting of such thresholds. This approach also permits more objective assessment of high and very high fracture risk to enable physicians to make choices not just about the need to treat but what agents to use in individual patients. SUMMARY Like all clinical tools, FRAX has limitations that need to be considered, but the use of fracture risk in deciding who to treat, when to treat and what agent to use is a mechanism to target treatment equitably to those at an increased risk of fracture.
Collapse
Affiliation(s)
- Eugene McCloskey
- Division of Clinical Medicine, School of Medicine and Population Health
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - Andre T H Tan
- Fast and Chronic Programmes, Alexandra Hospital, Queenstown
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Marian Schini
- Division of Clinical Medicine, School of Medicine and Population Health
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| |
Collapse
|
4
|
Phuong J, Moles R, Mason D, White C, Center J, Carter S. Osteoporosis screening in Australian community pharmacies: A mixed methods study. Health Promot J Austr 2024. [PMID: 38778716 DOI: 10.1002/hpja.876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024] Open
Abstract
ISSUES ADDRESSED Osteoporosis and poor bone health impact a large proportion of the Australian population, but is drastically underdiagnosed and undertreated. Community pharmacies are a strategic location for osteoporosis screening services due to their accessibility and the demographic profile of customers. The aim of this study was to develop, implement and evaluate a community pharmacy health promotion service centred on encouraging consumers to complete an anonymous osteoporosis screening survey called Know Your Bones. METHODS The implementation process was documented using the REAIM (reach, effectiveness, adoption, implementation, maintenance) framework. Uptake of the Know Your Bones screening tool was monitored anonymously with website traffic. Surveys and interviews were designed to capture consumer outcomes after screening. Semi-structured interviews were conducted with Australian community pharmacy stakeholders during design and implementation phases to explore their perspectives of the barriers and facilitators. RESULTS The service was implemented in 27 community pharmacies. There were 448 visits to the screening website. Interviews were conducted with 41 stakeholders. There were a range of factors that appeared to influence implementation of the service. Perceived acceptability was critical, which depended on staff training, pharmacists' altruism, and remuneration. Staff relied heavily on their existing close relationships with consumers. No consumers completed non-anonymous surveys or agreed to participate in interviews post-screening. CONCLUSION Using an implementation science approach, a community pharmacy osteoporosis screening service for the Australian context was designed and found to be acceptable to pharmacy staff and effective in reaching the target population. SO WHAT?: This low-cost and non-invasive health promotion has potential to sustainably increase national screening rates for osteoporosis.
Collapse
Affiliation(s)
- Jonathan Phuong
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- The Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Rebekah Moles
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Deborah Mason
- The Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Christopher White
- Department of Endocrinology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Jacqueline Center
- The Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Stephen Carter
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
5
|
Petersen TG, Abrahamsen B, Høiberg M, Rothmann MJ, Holmberg T, Gram J, Bech M, Åkesson KE, Javaid MK, Hermann AP, Rubin KH. Ten-year follow-up of fracture risk in a systematic population-based screening program: the risk-stratified osteoporosis strategy evaluation (ROSE) randomised trial. EClinicalMedicine 2024; 71:102584. [PMID: 38638398 PMCID: PMC11024575 DOI: 10.1016/j.eclinm.2024.102584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 04/20/2024] Open
Abstract
Background Osteoporotic fractures pose a growing public health concern. Osteoporosis is underdiagnosed and undertreated, highlighting the necessity of systematic screening programs. We aimed to evaluate the effectiveness of a two-step population-based osteoporotic screening program. Methods This ten-year follow-up of the Risk-stratified Osteoporosis Strategy Evaluation (ROSE) randomized trial tested the effectiveness of a screening program utilizing the Fracture Risk Assessment Tool (FRAX) for major osteoporotic fractures (MOF) to select women for dual-energy x-ray absorptiometry (DXA) scan following standard osteoporosis treatment. Women residing in the Region of Southern Denmark, aged 65-80, were randomised (single masked) into a screening or a control group by a computer program prior to inclusion and subsequently approached with a mailed questionnaire. Based on the questionnaire data, women in the screening group with a FRAX value ≥15% were invited for DXA scanning. The primary outcome was MOF derived from nationwide registers. ClinicalTrials.gov: NCT01388244, status: Completed. Findings All randomised women were included February 4, 2010-January 8, 2011, the same day as approached to participate. During follow-up, 7355 MOFs were observed. No differences in incidences of MOF were identified, comparing the 17,072 women in the screening group with the 17,157 controls in the intention-to-treat analysis (IRR 1.01, 0.95; 1.06). However, per-protocol, women DXA-scanned exhibited a 14% lower incidence of MOF (IRR 0.86, 0.78; 0.94) than controls with a FRAX value ≥15%. Similar trends were observed for hip fractures, all fractures, and mortality. Interpretation While the ROSE program had no overall effect on osteoporotic fracture incidence or mortality it showed a preventive effect for women at moderate to high risk who underwent DXA scans. Hence the overall effect might have been diluted by those who were not at an intervention level threshold risk or those who did not show up for DXA. Using self-administered questionnaires as screening tools may be inefficient for systematic screening due to the low and differential screening uptake. Funding INTERREG and the Region of Southern Denmark.
Collapse
Affiliation(s)
- Tanja Gram Petersen
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bo Abrahamsen
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Mikkel Høiberg
- Department of Internal Medicine, Hospital of Southern Norway, Arendal, Norway
| | - Mette Juel Rothmann
- Research Unit for Endocrinology, Odense University Hospital; University of Southern Denmark, Odense, Denmark
- Research Unit for Steno Diabetes Center Odense, Odense University Hospital; University of Southern Denmark, Odense, Denmark
| | | | - Jeppe Gram
- Department of Endocrinology, Esbjerg Hospital, University Hospital of Southern Denmark
| | - Mickael Bech
- Department of Political Science and Public Management, University of Southern Denmark, Odense, Denmark
| | - Kristina E. Åkesson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences Malmö, Lund University, Sweden and Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden
| | - M Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, United Kingdom
| | - Anne Pernille Hermann
- Research Unit for Endocrinology, Odense University Hospital; University of Southern Denmark, Odense, Denmark
| | - Katrine Hass Rubin
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
6
|
Merlijn T, Swart KMA, Niemeijer C, van der Horst HE, Netelenbos CJ, Elders PJM. The yield of routine laboratory examination in osteoporosis evaluation in primary care. Osteoporos Int 2024; 35:911-918. [PMID: 38494549 PMCID: PMC11031471 DOI: 10.1007/s00198-024-07042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/14/2024] [Indexed: 03/19/2024]
Abstract
This study evaluated the yield of routine laboratory examination in a large population of older women in primary care. The prevalence of laboratory abnormalities was low and the clinical consequences in follow-up were limited. There was a weak association of laboratory abnormalities with osteoporosis but no association with vertebral fractures and recent fractures. PURPOSE Most osteoporosis guidelines advice routine laboratory examination. We have investigated the yield of laboratory examinations in facture risk evaluation of elderly women in primary care. METHODS We assessed the prevalence of laboratory abnormalities and their association with risk factors for fractures, recent fractures, low bone mineral density (BMD), and prevalent vertebral fracture in 8996 women ≥ 65 years of age participating in a primary care fracture risk screening study. In a sample of 2208 of these participants, we also evaluated the medical consequences in the medical records during a follow-up period of ≥ 1 year. RESULTS Vitamin D deficiency (< 30 nmol/L) was present in 13% and insufficiency (< 50 nmol/L) in 43% of the study sample. The prevalence of other laboratory abnormalities (ESR, calcium, creatinine, FT4) was 4.6% in women with risk factors for fractures, 6.1% in women with low BMD (T-score ≤ - 2.5), 6.0% after a prevalent vertebral fracture, 5.2% after a recent fracture and 2.6% in the absence of important risk factors for fractures. Laboratory abnormalities other than vitamin D were associated with low BMD (OR 1.4, 95%CI 1.1-1.8) but not with prevalent vertebral fractures nor recent fractures. Low BMD was associated with renal failure (OR 2.0, 95%CI 1.3-3.4), vitamin D insufficiency (OR 1.2, 95%CI 1.0-1.3) and deficiency (OR 1.3, 95%CI 1.1-.5). In the follow-up period, 82% of the laboratory abnormalities did not result in a new diagnosis or treatment reported in the medical records. CONCLUSIONS We identified a low prevalence of laboratory abnormalities in a primary care population of older women and the majority of these findings had no medical consequences.
Collapse
Affiliation(s)
- Thomas Merlijn
- Department of General Practice, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Karin M A Swart
- Department Research, PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | - Christy Niemeijer
- Stichting Artsen Laboratorium en Trombosedienst, Koog Aan de Zaan, Zaanstad, The Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Coen J Netelenbos
- Department of Internal Medicine, Endocrine Section, Amsterdam UMC, Amsterdam, The Netherlands
| | - Petra J M Elders
- Department of General Practice, Amsterdam UMC, Amsterdam, The Netherlands
| |
Collapse
|
7
|
Adami G, Rossini M, Gatti D, Serpi P, Fabrizio C, Lovato R. New point-of-care calcaneal ultrasound densitometer (Osteosys BeeTLE) compared to standard dual-energy X-ray absorptiometry (DXA). Sci Rep 2024; 14:6898. [PMID: 38519548 PMCID: PMC10959987 DOI: 10.1038/s41598-024-56787-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
Dual-energy X-ray absorptiometry (DXA) represents the gold standard for measuring bone mineral density (BMD). However, its size and bulkiness limit its use in mass screening. Portable and easily accessible instruments are more suitable for this purpose. We conducted a study to assess the repeatability, sensitivity, accuracy, and validation of a new ultrasound densitometer for the calcaneus (OsteoSys BeeTLe) compared to standard DXA. BMD (g/cm2) was measured at the femoral and lumbar spine levels using DXA (Discovery Acclaim (Hologic, Waltham, MA, USA) or Lunar Prodigy (GE Healthcare, Madison, WI, USA) devices). Bone Quality Index (BQI, a dimensionless measure of bone quality derived from measures of SOS [Speed Of Sound] and BUA [broadband ultrasound attenuation]) was measured with OsteoSys BeeTLe. The Bland-Altman test and simple linear regression were used to evaluate the association between values measured with the two instruments. Additionally, the ability of the T-score calculated with BeeTLe to identify patients with previous osteoporotic fractures was tested using ROC curves. A total of 201 patients (94.5% females) with a mean age of 62.1 ± 10.2 were included in the study. The BeeTLe instrument showed a coefficient of variation (CV, in 75 repeated measurements) of 1.21%, which was not statistically different from the CV of DXA (1.20%). We found a significant association between BQI and BMD at the femoral neck (r2 = 0.500, p < 0.0001), total femur (r2 = 0.545, p < 0.0001), and lumbar spine (r2 = 0.455, p < 0.0001). T-scores bias were 0.215 (SD 0.876), 0.021 (SD 0.889) and 0.523 (SD 0.092), for femoral neck, total hip and lumbar spine respectively. AUC for discriminating fracture and non-fractured patients were not significantly different with OsteoSys BeeTLe and standard DXA. In this preliminary study, BeeTLe, a new point-of-care ultrasound densitometer, demonstrated good repeatability and performance similar to DXA. Therefore, its use can be proposed in screening for osteoporosis.
Collapse
Affiliation(s)
- Giovanni Adami
- Rheumatology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Pz Scuro 10, 37134, Verona, Italy.
| | - Maurizio Rossini
- Rheumatology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Pz Scuro 10, 37134, Verona, Italy
| | - Davide Gatti
- Rheumatology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Pz Scuro 10, 37134, Verona, Italy
| | | | | | - Roberto Lovato
- Bone Specialist Unit, Ospedale Casa di Cura Villa Berica, Vicenza, Italy
| |
Collapse
|
8
|
Schini M, Johansson H, Harvey NC, Lorentzon M, Kanis JA, McCloskey EV. An overview of the use of the fracture risk assessment tool (FRAX) in osteoporosis. J Endocrinol Invest 2024; 47:501-511. [PMID: 37874461 PMCID: PMC10904566 DOI: 10.1007/s40618-023-02219-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023]
Abstract
FRAX®, a simple-to-use fracture risk calculator, was first released in 2008 and since then has been used increasingly worldwide. By calculating the 10-year probabilities of a major osteoporotic fracture and hip fracture, it assists clinicians when deciding whether further investigation, for example a bone mineral density measurement (BMD), and/or treatment is needed to prevent future fractures. In this review, we explore the literature around osteoporosis and how FRAX has changed its management. We present the characteristics of this tool and describe the use of thresholds (diagnostic and therapeutic). We also present arguments as to why screening with FRAX should be considered. FRAX has several limitations which are described in this review. This review coincides with the release of a version, FRAXplus, which addresses some of these limitations.
Collapse
Affiliation(s)
- M Schini
- Department of Oncology & Metabolism, Metabolic Bone Centre, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK.
| | - H Johansson
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - N C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - M Lorentzon
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - J A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - E V McCloskey
- Department of Oncology & Metabolism, Metabolic Bone Centre, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| |
Collapse
|
9
|
Zhang YY, Xie N, Sun XD, Nice EC, Liou YC, Huang C, Zhu H, Shen Z. Insights and implications of sexual dimorphism in osteoporosis. Bone Res 2024; 12:8. [PMID: 38368422 PMCID: PMC10874461 DOI: 10.1038/s41413-023-00306-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/04/2023] [Accepted: 11/27/2023] [Indexed: 02/19/2024] Open
Abstract
Osteoporosis, a metabolic bone disease characterized by low bone mineral density and deterioration of bone microarchitecture, has led to a high risk of fatal osteoporotic fractures worldwide. Accumulating evidence has revealed that sexual dimorphism is a notable feature of osteoporosis, with sex-specific differences in epidemiology and pathogenesis. Specifically, females are more susceptible than males to osteoporosis, while males are more prone to disability or death from the disease. To date, sex chromosome abnormalities and steroid hormones have been proven to contribute greatly to sexual dimorphism in osteoporosis by regulating the functions of bone cells. Understanding the sex-specific differences in osteoporosis and its related complications is essential for improving treatment strategies tailored to women and men. This literature review focuses on the mechanisms underlying sexual dimorphism in osteoporosis, mainly in a population of aging patients, chronic glucocorticoid administration, and diabetes. Moreover, we highlight the implications of sexual dimorphism for developing therapeutics and preventive strategies and screening approaches tailored to women and men. Additionally, the challenges in translating bench research to bedside treatments and future directions to overcome these obstacles will be discussed.
Collapse
Affiliation(s)
- Yuan-Yuan Zhang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
| | - Na Xie
- West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, 610041, China
| | - Xiao-Dong Sun
- West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, 610041, China
| | - Edouard C Nice
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, VIC, 3800, Australia
| | - Yih-Cherng Liou
- Department of Biological Sciences, Faculty of Science, National University of Singapore, Singapore, 117543, Republic of Singapore
| | - Canhua Huang
- Department of Biotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, and West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, 610041, China
| | - Huili Zhu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Department of Reproductive Medicine, West China Second University Hospital of Sichuan University, Chengdu, China.
| | - Zhisen Shen
- Department of Otorhinolaryngology and Head and Neck Surgery, The Affiliated Lihuili Hospital, Ningbo University, 315040, Ningbo, Zhejiang, China.
| |
Collapse
|
10
|
Lu K, Wu YM, Shi Q, Gong YQ, Zhang T, Li C. A novel fracture liaison service using digital health: impact on mortality in hospitalized elderly osteoporotic fracture patients. Osteoporos Int 2024; 35:53-67. [PMID: 37698600 DOI: 10.1007/s00198-023-06905-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/30/2023] [Indexed: 09/13/2023]
Abstract
We examined the performance of an intelligent fracture liaison service (FLS) assisted by digital health (DH) to reduce all-cause mortality (ACM) risk. According to our findings, the new FLS reduced ACM by 36%. INTRODUCTION A well-designed secondary prevention program known as FLS enhances the bone densitometry-based assessment rate as well as osteoporosis (OP) medication usage following a fracture. However, there are only a few reports on FLS incorporating DH, and it remains unclear whether this integration has influenced patient ACM, which refers to the overall death rate from any cause during the study period. METHODS This retrospective observational study was conducted on data from the Fragility Fracture Registration System database linked to the Regional Health Registration Platform of Kunshan City and the Population Death Registration System of Jiangsu Province for one tertiary-level A hospital in China. Patients aged ≥ 50 years, who experienced an OP fracture between January 1, 2017, and July 27, 2022, requiring hospitalization, were selected for analysis. We compared the outcomes of patients who received routine fragility fracture management (the no-FLS group) or FLS (the FLS group). We employed multivariable Cox regression with inverse probability weighting based on the propensity score (PS). RESULTS Of 2317 patients, 756 (32.6%) received FLS and 1561 (67.4%) did not. Using PS matching, we minimized the baseline characteristic differences between the two groups in the propensity score-matched samples, relative to the unmatched samples. Based on our analysis, the new FLS reduced ACM by 36% (hazard ratio [HR], 0.64; 95% confidence interval [CI], 0.47 to 0.87; P-value = 0.004). Moreover, FLS patients experienced further reductions in fall-related mortality, refracture rate, and total refracture-related hospital costs, and had increased dual-energy X-ray absorptiometry (DXA) testing and treatment initiation rates, relative to the no-FLS patients. CONCLUSIONS A new FLS model implementation assisted by DH can effectively reduce ACM among elderly patients with OP fractures requiring surgery. In future investigations, we recommend examining the scalability of this model.
Collapse
Affiliation(s)
- Ke Lu
- Department of Orthopedics, Affiliated Kunshan Hospital of Jiangsu University, No. 566 East of Qianjin Road, Suzhou, 215300, Jiangsu, China
| | - Ya-Ming Wu
- Department of Orthopedics, Affiliated Kunshan Hospital of Jiangsu University, No. 566 East of Qianjin Road, Suzhou, 215300, Jiangsu, China
| | - Qin Shi
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute of Soochow University, Suzhou, Jiangsu, China
| | - Ya-Qin Gong
- Information Department, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Ting Zhang
- Chronic Disease Department, Kunshan Center For Disease Control and Prevention, Suzhou, Jiangsu, China
| | - Chong Li
- Department of Orthopedics, Affiliated Kunshan Hospital of Jiangsu University, No. 566 East of Qianjin Road, Suzhou, 215300, Jiangsu, China.
| |
Collapse
|
11
|
Rani J, Swati S, Meeta M, Singh SH, Tanvir T, Madan A. Postmenopausal Osteoporosis: Menopause Hormone Therapy and Selective Estrogen Receptor Modulators. Indian J Orthop 2023; 57:105-114. [PMID: 38107817 PMCID: PMC10721581 DOI: 10.1007/s43465-023-01071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 12/19/2023]
Abstract
Introduction Osteoporosis is a debilitating silent disease with a huge socio-economic impact. Prevention strategies and early detection of osteoporosis need to be carried out in every health care unit to substantially reduce the fracture rates. Indian studies have indicated a knowledge gap on diagnosis and management of osteoporosis amongst medical professionals and consumers. Areas Covered This article reviews the evidences available on searches from PubMed and The National Library of Medicine, author's opinions based on clinical experience. There is a need for escalating the efforts to bridge the knowledge gap regarding various aspects of osteoporosis amongst professionals and consumers. Three indications for postmenopausal hormone therapy (HT), which have constantly withstood the test of time, are symptom relief, urogenital atrophy, and bone health. This article specifically focuses on management of postmenopausal osteoporosis by HT alone or in combinations. Expert Opinion Early menopause is within 10 years of menopause and late menopause is considered beyond 10 years of menopause. HT is a cost-effective therapy in the early post menopause especially in symptomatic women at risk for osteoporosis unless contraindicated. HT prevents all osteoporotic fractures even in low-risk population. All HT preparations including low dose and non-oral routes of estrogen are effective for bone health. The bone protective effect lasts while on HT. Extended use of HT in women after 10 years of menopause with reduced bone mass is an option after detailed counselling of the risk benefit analysis compared with the other available therapies for osteoporosis. The primary therapy to prevent bone loss in women with premature menopause and secondary amenorrhea is HT. HT work up and annual follow-up is essential before prescribing HT.
Collapse
|
12
|
Morin SN, Feldman S, Funnell L, Giangregorio L, Kim S, McDonald-Blumer H, Santesso N, Ridout R, Ward W, Ashe MC, Bardai Z, Bartley J, Binkley N, Burrell S, Butt D, Cadarette SM, Cheung AM, Chilibeck P, Dunn S, Falk J, Frame H, Gittings W, Hayes K, Holmes C, Ioannidis G, Jaglal SB, Josse R, Khan AA, McIntyre V, Nash L, Negm A, Papaioannou A, Ponzano M, Rodrigues IB, Thabane L, Thomas CA, Tile L, Wark JD. Actualisation 2023 des lignes directrices de pratique clinique pour la prise en charge de l’ostéoporose et la prévention des fractures au Canada. CMAJ 2023; 195:E1585-E1603. [PMID: 38011931 PMCID: PMC10681677 DOI: 10.1503/cmaj.221647-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Contexte: Au Canada, plus de 2 millions de personnes vivent avec l’ostéoporose, une maladie qui accroît le risque de fracture, ce qui fait augmenter la morbidité et la mortalité, et entraîne une perte de qualité de vie et d’autonomie. La présente actualisation des lignes directrices vise à accompagner les professionnelles et professionnels de la santé au Canada dans la prestation de soins visant à optimiser la santé osseuse et à prévenir les fractures chez les femmes ménopausées et les hommes de 50 ans et plus. Méthodes: Le présent document fournit une actualisation des lignes directrices de pratique clinique de 2010 d’Ostéoporose Canada sur le diagnostic et la prise en charge de l’ostéoporose au pays. Nous avons utilisé l’approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) et effectué l’assurance de la qualité conformément aux normes de qualité et de présentation des rapports de la grille AGREE II (Appraisal of Guidelines for Research & Evaluation). Les médecins de premier recours et les patientes et patients partenaires ont été représentés à tous les niveaux des comités et des groupes ayant participé à l’élaboration des lignes directrices, et ont participé à toutes les étapes du processus pour garantir la pertinence des informations pour les futurs utilisateurs et utilisatrices. Le processus de gestion des intérêts concurrents a été entamé avant l’élaboration des lignes directrices et s’est poursuivi sur toute sa durée, selon les principes du Réseau international en matière de lignes directrices. Dans la formulation des recommandations, nous avons tenu compte des avantages et des risques, des valeurs et préférences de la patientèle, des ressources, de l’équité, de l’acceptabilité et de la faisabilité; la force de chacune des recommandations a été déterminée en fonction du cadre GRADE. Recommandations: Les 25 recommandations et les 10 énoncés de bonne pratique sont répartis en sections : activité physique, alimentation, évaluation du risque de fracture, instauration du traitement, interventions pharmacologiques, durée et séquence du traitement, et monitorage. La prise en charge de l’ostéoporose devrait se fonder sur le risque de fracture, établi au moyen d’une évaluation clinique réalisée avec un outil d’évaluation du risque de fracture validé. L’activité physique, l’alimentation et la pharmacothérapie sont des éléments essentiels à la stratégie de prévention des fractures, qui devraient être personnalisés. Interprétation: Les présentes lignes directrices ont pour but d’outiller les professionnelles et professionnels de la santé et la patientèle afin qu’ensemble ils puissent parler de l’importance de la santé osseuse et du risque de fracture tout au long de la vie adulte avancée. La détection et la prise en charge efficace de la fragilité osseuse peuvent contribuer à réduire les fractures et à préserver la mobilité, l’autonomie et la qualité de vie.
Collapse
Affiliation(s)
- Suzanne N Morin
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Sidney Feldman
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Larry Funnell
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Lora Giangregorio
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Sandra Kim
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Heather McDonald-Blumer
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Nancy Santesso
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Rowena Ridout
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Wendy Ward
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Maureen C Ashe
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Zahra Bardai
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Joan Bartley
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Neil Binkley
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Steven Burrell
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Debra Butt
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Suzanne M Cadarette
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Angela M Cheung
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Phil Chilibeck
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Sheila Dunn
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Jamie Falk
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Heather Frame
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - William Gittings
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Kaleen Hayes
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Carol Holmes
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - George Ioannidis
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Susan B Jaglal
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Robert Josse
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Aliya A Khan
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Virginia McIntyre
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Lynn Nash
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Ahmed Negm
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Alexandra Papaioannou
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Matteo Ponzano
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Isabel B Rodrigues
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Lehana Thabane
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Christine A Thomas
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - Lianne Tile
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| | - John D Wark
- Université McGill (Morin), Montréal, Qc; Université de Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patientes et patients partenaires (Funnell, McIntyre, Bartley, Thomas); Université de Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Université Brock (Ward, Gittings), St. Catharines, Ont.; Université McMaster (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; Université du Wisconsin (Binkley), Madison, Wisc.; Université Dalhousie (Burrell], Halifax, N.-É.; Centre médical Menzies (Holmes), Morden, Man.; Université de Calgary (Negm), Calgary, Alb.; Université de la Colombie-Britannique (Ashe), Vancouver, C.-B.; Université de la Saskatchewan (Chilibeck), Saskatoon, Sask.; Université de la Colombie-Britannique (Ponzano), Kelowna, C.-B.; Université de Melbourne (Wark), Melbourne, Australie; Université du Manitoba (Falk, Frame), Winnipeg, Man.; Université Brown (Hayes), Providence, R.I
| |
Collapse
|
13
|
Morin SN, Feldman S, Funnell L, Giangregorio L, Kim S, McDonald-Blumer H, Santesso N, Ridout R, Ward W, Ashe MC, Bardai Z, Bartley J, Binkley N, Burrell S, Butt D, Cadarette SM, Cheung AM, Chilibeck P, Dunn S, Falk J, Frame H, Gittings W, Hayes K, Holmes C, Ioannidis G, Jaglal SB, Josse R, Khan AA, McIntyre V, Nash L, Negm A, Papaioannou A, Ponzano M, Rodrigues IB, Thabane L, Thomas CA, Tile L, Wark JD. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ 2023; 195:E1333-E1348. [PMID: 37816527 PMCID: PMC10610956 DOI: 10.1503/cmaj.221647] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older. METHODS This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework. RECOMMENDATIONS The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized. INTERPRETATION The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life.
Collapse
Affiliation(s)
- Suzanne N Morin
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI.
| | - Sidney Feldman
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Larry Funnell
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Lora Giangregorio
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Sandra Kim
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Heather McDonald-Blumer
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Nancy Santesso
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Rowena Ridout
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Wendy Ward
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Maureen C Ashe
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Zahra Bardai
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Joan Bartley
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Neil Binkley
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Steven Burrell
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Debra Butt
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Suzanne M Cadarette
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Angela M Cheung
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Phil Chilibeck
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Sheila Dunn
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Jamie Falk
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Heather Frame
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - William Gittings
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Kaleen Hayes
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Carol Holmes
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - George Ioannidis
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Susan B Jaglal
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Robert Josse
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Aliya A Khan
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Virginia McIntyre
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Lynn Nash
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Ahmed Negm
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Alexandra Papaioannou
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Matteo Ponzano
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Isabel B Rodrigues
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Lehana Thabane
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Christine A Thomas
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - Lianne Tile
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| | - John D Wark
- McGill University (Morin), Montréal, Que.; University of Toronto (Feldman, Kim, McDonald-Blumer, Ridout, Cheung, Josse, Tile, Bardai, Butt, Cadarette, Dunn, Jaglal), Toronto, Ont.; patient partners (Funnell, McIntyre, Bartley, Thomas); University of Waterloo (Giangregorio, Kim, McLaughlin, Rodrigues), Waterloo, Ont.; Brock University (Ward, Gittings), St. Catharines, Ont.; McMaster University (Santesso, Ioannidis, Khan, Nash, Thabane, Papaioannou), Hamilton, Ont.; University of Wisconsin (Binkley), Madison, Wisc.; Dalhousie University (Burrell), Halifax, NS; Menzies Medical Centre (Holmes), Morden, Man.; University of Calgary (Negm), Calgary, Alta.; University of British Columbia (Ashe), Vancouver, BC; University of Saskatchewan (Chilibeck), Saskatoon, Sask.; University of British Columbia (Ponzano), Kelowna, BC; University of Melbourne (Wark), Melbourne, Australia; University of Manitoba (Falk, Frame), Winnipeg, Man.; Brown University (Hayes), Providence, RI
| |
Collapse
|
14
|
Barańska A, Drop B, Religioni U, Dolar-Szczasny J, Malm M, Wdowiak K, Bogdan M, Kłak A, Merks P, Rejdak R. Assessment of Awareness and Knowledge about Osteoporosis in Relation to Health Prevention among Patients Treated in Osteoporosis Clinics. J Clin Med 2023; 12:6157. [PMID: 37834801 PMCID: PMC10573914 DOI: 10.3390/jcm12196157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/19/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
The increasing incidence of osteoporosis indicates that the disease is a serious public health problem, with about 200 million people being affected worldwide. The aims of this research are to assess the awareness and knowledge about osteoporosis in relation to risk factors, health condition, supplementation used, socio-demographic factors and other variables among osteoporosis patients. The study was conducted in 2016-2018 in osteoporosis clinics in Poland. The study involved 312 patients with a diagnosis of osteoporosis. In the diagnostic survey method, the authors' own questionnaire was used. The results indicate that the more frequent the symptoms associated with the disease, the lower the general self-assessment of the health condition of the respondents (rho = -0.682, p < 0.001). In addition, almost half of the respondents stated that their knowledge of osteoporosis is negligible. Moreover, the use of dietary supplements significantly differentiated respondents in terms of health self-assessed (p < 0.001), and it is noteworthy that users of dietary supplements assessed their health significantly better. We also saw a statistically significant relationship between the self-assessment of knowledge about osteoporosis and the use of dietary supplements (p < 0.001). Accordingly, significantly more respondents rating their knowledge as good or very good used dietary supplements. The conducted study demonstrates the need to educate patients and implement educational programs at central and provincial levels to improve patient knowledge concerning the disease. Supporting adaptation to chronic diseases and appropriate therapeutic management may contribute to improved osteoporosis treatment and enhanced patient quality of life.
Collapse
Affiliation(s)
- Agnieszka Barańska
- Department of Medical Informatics and Statistics with e-Health Lab, Medical University of Lublin, 20-059 Lublin, Poland; (B.D.); (M.M.)
| | - Bartłomiej Drop
- Department of Medical Informatics and Statistics with e-Health Lab, Medical University of Lublin, 20-059 Lublin, Poland; (B.D.); (M.M.)
| | - Urszula Religioni
- School of Public Health, Centre of Postgraduate Medical Education of Warsaw, 01-813 Warsaw, Poland;
| | - Joanna Dolar-Szczasny
- Department of General and Pediatric Ophtalmology, Medical University of Lublin, 20-059 Lublin, Poland; (J.D.-S.); (R.R.)
| | - Maria Malm
- Department of Medical Informatics and Statistics with e-Health Lab, Medical University of Lublin, 20-059 Lublin, Poland; (B.D.); (M.M.)
| | - Krystian Wdowiak
- Faculty of Medicine, Medical University of Lublin, 20-059 Lublin, Poland;
| | - Magdalena Bogdan
- Department of Social Medicine and Public Health, Warsaw Medical University, 02-007 Warsaw, Poland;
| | - Anna Kłak
- Department of Environmental Hazards Prevention, Allergology and Immunology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Piotr Merks
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszyński University, 01-815 Warsaw, Poland;
| | - Robert Rejdak
- Department of General and Pediatric Ophtalmology, Medical University of Lublin, 20-059 Lublin, Poland; (J.D.-S.); (R.R.)
| |
Collapse
|
15
|
Gates M, Pillay J, Nuspl M, Wingert A, Vandermeer B, Hartling L. Screening for the primary prevention of fragility fractures among adults aged 40 years and older in primary care: systematic reviews of the effects and acceptability of screening and treatment, and the accuracy of risk prediction tools. Syst Rev 2023; 12:51. [PMID: 36945065 PMCID: PMC10029308 DOI: 10.1186/s13643-023-02181-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 02/02/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND To inform recommendations by the Canadian Task Force on Preventive Health Care, we reviewed evidence on the benefits, harms, and acceptability of screening and treatment, and on the accuracy of risk prediction tools for the primary prevention of fragility fractures among adults aged 40 years and older in primary care. METHODS For screening effectiveness, accuracy of risk prediction tools, and treatment benefits, our search methods involved integrating studies published up to 2016 from an existing systematic review. Then, to locate more recent studies and any evidence relating to acceptability and treatment harms, we searched online databases (2016 to April 4, 2022 [screening] or to June 1, 2021 [predictive accuracy]; 1995 to June 1, 2021, for acceptability; 2016 to March 2, 2020, for treatment benefits; 2015 to June 24, 2020, for treatment harms), trial registries and gray literature, and hand-searched reviews, guidelines, and the included studies. Two reviewers selected studies, extracted results, and appraised risk of bias, with disagreements resolved by consensus or a third reviewer. The overview of reviews on treatment harms relied on one reviewer, with verification of data by another reviewer to correct errors and omissions. When appropriate, study results were pooled using random effects meta-analysis; otherwise, findings were described narratively. Evidence certainty was rated according to the GRADE approach. RESULTS We included 4 randomized controlled trials (RCTs) and 1 controlled clinical trial (CCT) for the benefits and harms of screening, 1 RCT for comparative benefits and harms of different screening strategies, 32 validation cohort studies for the calibration of risk prediction tools (26 of these reporting on the Fracture Risk Assessment Tool without [i.e., clinical FRAX], or with the inclusion of bone mineral density (BMD) results [i.e., FRAX + BMD]), 27 RCTs for the benefits of treatment, 10 systematic reviews for the harms of treatment, and 12 studies for the acceptability of screening or initiating treatment. In females aged 65 years and older who are willing to independently complete a mailed fracture risk questionnaire (referred to as "selected population"), 2-step screening using a risk assessment tool with or without measurement of BMD probably (moderate certainty) reduces the risk of hip fractures (3 RCTs and 1 CCT, n = 43,736, absolute risk reduction [ARD] = 6.2 fewer in 1000, 95% CI 9.0-2.8 fewer, number needed to screen [NNS] = 161) and clinical fragility fractures (3 RCTs, n = 42,009, ARD = 5.9 fewer in 1000, 95% CI 10.9-0.8 fewer, NNS = 169). It probably does not reduce all-cause mortality (2 RCTs and 1 CCT, n = 26,511, ARD = no difference in 1000, 95% CI 7.1 fewer to 5.3 more) and may (low certainty) not affect health-related quality of life. Benefits for fracture outcomes were not replicated in an offer-to-screen population where the rate of response to mailed screening questionnaires was low. For females aged 68-80 years, population screening may not reduce the risk of hip fractures (1 RCT, n = 34,229, ARD = 0.3 fewer in 1000, 95% CI 4.2 fewer to 3.9 more) or clinical fragility fractures (1 RCT, n = 34,229, ARD = 1.0 fewer in 1000, 95% CI 8.0 fewer to 6.0 more) over 5 years of follow-up. The evidence for serious adverse events among all patients and for all outcomes among males and younger females (<65 years) is very uncertain. We defined overdiagnosis as the identification of high risk in individuals who, if not screened, would never have known that they were at risk and would never have experienced a fragility fracture. This was not directly reported in any of the trials. Estimates using data available in the trials suggest that among "selected" females offered screening, 12% of those meeting age-specific treatment thresholds based on clinical FRAX 10-year hip fracture risk, and 19% of those meeting thresholds based on clinical FRAX 10-year major osteoporotic fracture risk, may be overdiagnosed as being at high risk of fracture. Of those identified as being at high clinical FRAX 10-year hip fracture risk and who were referred for BMD assessment, 24% may be overdiagnosed. One RCT (n = 9268) provided evidence comparing 1-step to 2-step screening among postmenopausal females, but the evidence from this trial was very uncertain. For the calibration of risk prediction tools, evidence from three Canadian studies (n = 67,611) without serious risk of bias concerns indicates that clinical FRAX-Canada may be well calibrated for the 10-year prediction of hip fractures (observed-to-expected fracture ratio [O:E] = 1.13, 95% CI 0.74-1.72, I2 = 89.2%), and is probably well calibrated for the 10-year prediction of clinical fragility fractures (O:E = 1.10, 95% CI 1.01-1.20, I2 = 50.4%), both leading to some underestimation of the observed risk. Data from these same studies (n = 61,156) showed that FRAX-Canada with BMD may perform poorly to estimate 10-year hip fracture risk (O:E = 1.31, 95% CI 0.91-2.13, I2 = 92.7%), but is probably well calibrated for the 10-year prediction of clinical fragility fractures, with some underestimation of the observed risk (O:E 1.16, 95% CI 1.12-1.20, I2 = 0%). The Canadian Association of Radiologists and Osteoporosis Canada Risk Assessment (CAROC) tool may be well calibrated to predict a category of risk for 10-year clinical fractures (low, moderate, or high risk; 1 study, n = 34,060). The evidence for most other tools was limited, or in the case of FRAX tools calibrated for countries other than Canada, very uncertain due to serious risk of bias concerns and large inconsistency in findings across studies. Postmenopausal females in a primary prevention population defined as <50% prevalence of prior fragility fracture (median 16.9%, range 0 to 48% when reported in the trials) and at risk of fragility fracture, treatment with bisphosphonates as a class (median 2 years, range 1-6 years) probably reduces the risk of clinical fragility fractures (19 RCTs, n = 22,482, ARD = 11.1 fewer in 1000, 95% CI 15.0-6.6 fewer, [number needed to treat for an additional beneficial outcome] NNT = 90), and may reduce the risk of hip fractures (14 RCTs, n = 21,038, ARD = 2.9 fewer in 1000, 95% CI 4.6-0.9 fewer, NNT = 345) and clinical vertebral fractures (11 RCTs, n = 8921, ARD = 10.0 fewer in 1000, 95% CI 14.0-3.9 fewer, NNT = 100); it may not reduce all-cause mortality. There is low certainty evidence of little-to-no reduction in hip fractures with any individual bisphosphonate, but all provided evidence of decreased risk of clinical fragility fractures (moderate certainty for alendronate [NNT=68] and zoledronic acid [NNT=50], low certainty for risedronate [NNT=128]) among postmenopausal females. Evidence for an impact on risk of clinical vertebral fractures is very uncertain for alendronate and risedronate; zoledronic acid may reduce the risk of this outcome (4 RCTs, n = 2367, ARD = 18.7 fewer in 1000, 95% CI 25.6-6.6 fewer, NNT = 54) for postmenopausal females. Denosumab probably reduces the risk of clinical fragility fractures (6 RCTs, n = 9473, ARD = 9.1 fewer in 1000, 95% CI 12.1-5.6 fewer, NNT = 110) and clinical vertebral fractures (4 RCTs, n = 8639, ARD = 16.0 fewer in 1000, 95% CI 18.6-12.1 fewer, NNT=62), but may make little-to-no difference in the risk of hip fractures among postmenopausal females. Denosumab probably makes little-to-no difference in the risk of all-cause mortality or health-related quality of life among postmenopausal females. Evidence in males is limited to two trials (1 zoledronic acid, 1 denosumab); in this population, zoledronic acid may make little-to-no difference in the risk of hip or clinical fragility fractures, and evidence for all-cause mortality is very uncertain. The evidence for treatment with denosumab in males is very uncertain for all fracture outcomes (hip, clinical fragility, clinical vertebral) and all-cause mortality. There is moderate certainty evidence that treatment causes a small number of patients to experience a non-serious adverse event, notably non-serious gastrointestinal events (e.g., abdominal pain, reflux) with alendronate (50 RCTs, n = 22,549, ARD = 16.3 more in 1000, 95% CI 2.4-31.3 more, [number needed to treat for an additional harmful outcome] NNH = 61) but not with risedronate; influenza-like symptoms with zoledronic acid (5 RCTs, n = 10,695, ARD = 142.5 more in 1000, 95% CI 105.5-188.5 more, NNH = 7); and non-serious gastrointestinal adverse events (3 RCTs, n = 8454, ARD = 64.5 more in 1000, 95% CI 26.4-13.3 more, NNH = 16), dermatologic adverse events (3 RCTs, n = 8454, ARD = 15.6 more in 1000, 95% CI 7.6-27.0 more, NNH = 64), and infections (any severity; 4 RCTs, n = 8691, ARD = 1.8 more in 1000, 95% CI 0.1-4.0 more, NNH = 556) with denosumab. For serious adverse events overall and specific to stroke and myocardial infarction, treatment with bisphosphonates probably makes little-to-no difference; evidence for other specific serious harms was less certain or not available. There was low certainty evidence for an increased risk for the rare occurrence of atypical femoral fractures (0.06 to 0.08 more in 1000) and osteonecrosis of the jaw (0.22 more in 1000) with bisphosphonates (most evidence for alendronate). The evidence for these rare outcomes and for rebound fractures with denosumab was very uncertain. Younger (lower risk) females have high willingness to be screened. A minority of postmenopausal females at increased risk for fracture may accept treatment. Further, there is large heterogeneity in the level of risk at which patients may be accepting of initiating treatment, and treatment effects appear to be overestimated. CONCLUSION An offer of 2-step screening with risk assessment and BMD measurement to selected postmenopausal females with low prevalence of prior fracture probably results in a small reduction in the risk of clinical fragility fracture and hip fracture compared to no screening. These findings were most applicable to the use of clinical FRAX for risk assessment and were not replicated in the offer-to-screen population where the rate of response to mailed screening questionnaires was low. Limited direct evidence on harms of screening were available; using study data to provide estimates, there may be a moderate degree of overdiagnosis of high risk for fracture to consider. The evidence for younger females and males is very limited. The benefits of screening and treatment need to be weighed against the potential for harm; patient views on the acceptability of treatment are highly variable. SYSTEMATIC REVIEW REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO): CRD42019123767.
Collapse
Affiliation(s)
- Michelle Gates
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Jennifer Pillay
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada.
| | - Megan Nuspl
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Aireen Wingert
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Ben Vandermeer
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Lisa Hartling
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| |
Collapse
|
16
|
Belaya Z, Rozhinskaya L, Dedov I, Drapkina O, Fadeev V, Golounina O, Lesnyak O, Mamedova E, Melnichenko G, Petraikin A, Rodionova S, Skripnikova I, Tkacheva O, Toroptsova N, Yureneva S, Kanis JA. A summary of the Russian clinical guidelines on the diagnosis and treatment of osteoporosis. Osteoporos Int 2023; 34:429-447. [PMID: 36651943 DOI: 10.1007/s00198-022-06667-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/29/2022] [Indexed: 01/19/2023]
Abstract
UNLABELLED 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.
Collapse
Affiliation(s)
- Zhanna Belaya
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia.
| | - Liudmila Rozhinskaya
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia
| | - Ivan Dedov
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia
| | - Oksana Drapkina
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Valentin Fadeev
- Department of Endocrinology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Olga Golounina
- Department of Endocrinology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Olga Lesnyak
- Family Medicine Department-Western State Medical University Named After I.I. Mechnikov, St. Petersburg, Russia
| | - Elizaveta Mamedova
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia
| | - Galina Melnichenko
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia
| | - Alexey Petraikin
- Department of Radiation Diagnostics, Research and Practical Clinical Center for Diagnostics, Telemedicine Technologies of Moscow Health Care Department, Moscow, Russia
| | - Svetlana Rodionova
- National Medical Research Center of Traumatology and Orthopedics named after. N.N. Priorov, Moscow, Russia
| | - Irina Skripnikova
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Olga Tkacheva
- Russian National Research Medical University Named After N.I. Pirogov, Moscow, Russia
| | | | - Svetlana Yureneva
- Department of Gynecological Endocrinology, National Medical Research Center for Obstetrics, Gynecology and Perinatology Named After V.I. Kulakov, Moscow, Russia
| | - John A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Center for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| |
Collapse
|
17
|
Laird C, Benson H, Williams KA. Pharmacist interventions in osteoporosis management: a systematic review. Osteoporos Int 2023; 34:239-254. [PMID: 36239755 PMCID: PMC9852145 DOI: 10.1007/s00198-022-06561-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/23/2022] [Indexed: 01/24/2023]
Abstract
UNLABELLED Internationally, there is an osteoporosis treatment gap, which pharmacists may assist in closing. This review identifies pharmacist interventions for improving osteoporosis management and evaluates their effectiveness. Pharmacist interventions are shown to improve osteoporosis management in terms of increasing investigation and treatment commencement and osteoporosis therapy adherence. INTRODUCTION This review identifies pharmacist interventions for improving osteoporosis management and evaluates their effectiveness. METHODS A literature search using PubMed, Embase, International Pharmaceutical Abstracts, and Cumulative Index to Nursing and Allied Health Literature was undertaken from database inception to June 2022. Randomised controlled trials were eligible, if they included adults diagnosed with or at risk of osteoporosis and assessed pharmacist interventions to improve osteoporosis management. Outcomes regarding investigation, treatment, adherence and patient knowledge were evaluated using qualitative analysis. The quality of included studies was assessed using the Critical Appraisal Skills Programme checklists and the Cochrane Collaboration tool to assess the risk of bias (Rob 2.0). RESULTS Sixteen articles (12 different studies) with a total of 16,307 participants, published between 2005 and 2018 were included. Pharmacist interventions were classified into two categories, those targeting investigation and treatment (n = 10) and those targeting adherence (n = 2). The impact of the intervention on patient knowledge was considered by studies targeting both investigation and treatment (n = 2) and adherence (n = 1). Pharmacist interventions demonstrated benefit for all outcomes; however, the extent to which conclusions can be drawn on their effectiveness is limited by the heterogeneity of interventions employed and methodological issues identified. Patient education and counselling were identified as a cornerstone of pharmacist interventions targeting both investigation and treatment and adherence, along with the importance of pharmacist and physician collaboration. CONCLUSION Pharmacist interventions show promise for improving osteoporosis management. The potential for pharmacists to contribute to closing the osteoporosis treatment gap through undertaking population screening has been identified.
Collapse
Affiliation(s)
- Catherine Laird
- Graduate School of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia.
| | - Helen Benson
- Graduate School of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia
| | - Kylie A Williams
- Graduate School of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia
| |
Collapse
|
18
|
Geusens P, Appelman-Dijkstra N, Lems W, van den Bergh J. Romosozumab for the treatment of postmenopausal women at high risk of fracture. Expert Opin Biol Ther 2023; 23:11-19. [PMID: 36440489 DOI: 10.1080/14712598.2022.2152320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Romosozumab is a monoclonal antibody that binds to sclerostin (an inhibitor of the Wingless-related integration site (Wnt) signaling pathway). It is a new osteoanabolic drug that simultaneously increases bone formation and decreases bone resorption. It has recently been approved by the US and EU authorities in postmenopausal women with at high risk of fractures. AREAS COVERED The literature on romosozumab in preclinical and in phase II and III clinical studies has been reviewed about the effect on bone, bone markers, and fracture reduction and its safety. EXPERT OPINION Compared to antiresorptive agents, its unique mechanism of action results in a quicker and greater increase in bone mineral density, it repairs and restores trabecular and cortical bone microarchitecture, and reduces fracture risk more rapidly and more effectively than alendronate, with persisting effects for at least two years after transition to antiresorptive agents. This finding has introduced the concept that, in patients at very high risk of fractures, the optimal sequence of treatment is to start with an osteoanabolic agent, followed by a potent AR drug. Recent national and international guidelines recommend the use of romosozumab as an initial treatment in patients at very high fracture risk without a history of stroke or myocardial infarction.
Collapse
Affiliation(s)
- Piet Geusens
- Department of Rheumatology, University Maastricht, Minderbroedersberg 4-6, 6211 LK Maastricht, Netherlands
| | - Natasha Appelman-Dijkstra
- Department of Internal Medicine-Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Willem Lems
- Department of Rheumatology, Amsterdam University Medical Centre, De Boelelaan 1117 1081 HV Amsterdam, Netherlands
| | - Joop van den Bergh
- Department of Internal Medicine, VieCuri Medical Centre, Tegelseweg 210, 5912 BL Venlo, Netherlands
| |
Collapse
|
19
|
El Miedany Y, Gadallah NA, Toth M. Optimizing osteoporosis management: targeting to treat — an initiative by the Egyptian Academy of Bone Health. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00161-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AbstractThe overarching goal of treating osteoporotic patients is to reduce the incidence of fractures, yet interventions that support early detection of osteoporosis and prevention of osteoporotic fractures are underutilized. Osteoporosis and, specifically, the associated burden of fractures call for a screening strategy offering an opportunity to intervene early. Such strategy should be clinically feasible and cost-effective, aiming to identify and treat subjects at high or very high risk of fragility fracture.The low sensitivity of bone mineral density measurements in identifying high-risk patients is evidenced by the high number of osteoporotic fractures occurring in subjects with BMD values above threshold required for a diagnosis of osteoporosis. Consequently, DXA scanning is not considered appropriate as a public screening tool identifying patients at risk of sustaining fragility fractures and current efforts focus on identifying non-BMD-related risk factors.In Egypt, we are fortunate in having all modalities of osteoporosis therapy and assessment tools available, yet there remains a significant treatment gap in osteoporosis management. Furthermore, screening for fracture risk is not currently advocated nationally. This manuscript describes a national initiative for a population screening intervention to identify patients at risk of developing a fragility fracture aiming to reduce fragility fractures especially in older adults.
Collapse
|
20
|
Silva BC, Madeira M, d'Alva CB, Maeda SS, de Holanda NCP, Ohe MN, Szejnfeld V, Zerbini CAF, de Paula FJA, Bandeira F. Definition and management of very high fracture risk in women with postmenopausal osteoporosis: a position statement from the Brazilian Society of Endocrinology and Metabolism (SBEM) and the Brazilian Association of Bone Assessment and Metabolism (ABRASSO). ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:591-603. [PMID: 36191263 PMCID: PMC10118822 DOI: 10.20945/2359-3997000000522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Several drugs are available for the treatment of osteoporosis in postmenopausal women. Over the last decades, most patients requiring pharmacological intervention were offered antiresorptive drugs as first-line therapy, while anabolic agents were considered a last resource for those with therapeutic failure. However, recent randomized trials in patients with severe osteoporosis have shown that anabolic agents reduce fractures to a greater extent than antiresorptive medications. Additionally, evidence indicates that increases in bone mineral density (BMD) are maximized when patients are treated with anabolic agents first, followed by antiresorptive therapy. This evidence is key, considering that greater increases in BMD during osteoporosis treatment are associated with a more pronounced reduction in fracture risk. Thus, international guidelines have recently proposed an individualized approach to osteoporosis treatment based on fracture risk stratification, in which the stratification risk has been refined to include a category of patients at very high risk of fracture who should be managed with anabolic agents as first-line therapy. In this document, the Brazilian Society of Endocrinology and Metabolism and the Brazilian Association of Bone Assessment and Metabolism propose the definition of very high risk of osteoporotic fracture in postmenopausal women, for whom anabolic agents should be considered as first-line therapy. This document also reviews the factors associated with increased fracture risk, trials comparing anabolic versus antiresorptive agents, efficacy of anabolic agents in patients who are treatment naïve versus those previously treated with antiresorptive agents, and safety of anabolic agents.
Collapse
Affiliation(s)
- Barbara C Silva
- Unidade de Endocrinologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil
- Unidade de Endocrinologia, Hospital Felício Rocho, Belo Horizonte, MG, Brasil
- Departamento de Medicina, Centro Universitário de Belo Horizonte (UNI-BH), Belo Horizonte, MG, Brasil,
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Miguel Madeira
- Divisão de Endocrinologia e Metabolismo, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Catarina Brasil d'Alva
- Departamento de Medicina Clínica, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Sergio Setsuo Maeda
- Unidade de Endocrinologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Narriane Chaves Pereira de Holanda
- Divisão de Endocrinologia e Metabolismo, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Monique Nakayama Ohe
- Unidade de Endocrinologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Vera Szejnfeld
- Divisão de Reumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Cristiano A F Zerbini
- Centro Paulista de Investigação Clínica, São Paulo, SP, Brasil
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Francisco José Albuquerque de Paula
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Francisco Bandeira
- Divisão de Endocrinologia e Metabolismo, Faculdade de Medicina, Universidade de Pernambuco, Recife, PE, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| |
Collapse
|
21
|
Geusens P, Appelman-Dijkstra NM, Zillikens MC, Willems H, Lems WF, van den Bergh J. How to implement guidelines and models of care. Best Pract Res Clin Rheumatol 2022; 36:101759. [PMID: 35729036 DOI: 10.1016/j.berh.2022.101759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In subjects older than 50 years, the presence of clinical risk factors (CRFs) for fractures or a recent fracture is the cornerstone for case finding. In patients who are clinically at high short- and long-term risk of fractures (those with a recent clinical fracture or with multiple CRFs), further assessment with bone mineral density (BMD) measurement using dual-energy absorptiometry (DXA), imaging of the spine, fall risk evaluation and laboratory examination contributes to treatment decisions according to the height and modifiability of fracture risk. Treatment is available with anti-resorptive and anabolic drugs, and from the start of treatment a lifelong strategy is needed to decide about continuous, intermittent, and sequential therapy. Implementation of guidelines requires further initiatives for improving case finding, public awareness about osteoporosis and national policies on reimbursement of assessment and therapy.
Collapse
Affiliation(s)
- Piet Geusens
- Department of Rheumatology, Maastricht University, Minderbroedersberg 4-6, 6211 LK Maastricht, Netherlands.
| | - Natasha M Appelman-Dijkstra
- Department of Internal Medicine-Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Netherlands.
| | - Hanna Willems
- Department of Geriatrics, Amsterdam University Medical Center, De Boelelaan 1117 1081 HV Amsterdam, Netherlands.
| | - Willem F Lems
- Department of Rheumatology, Amsterdam University Medical Center, De Boelelaan 1117 1081 HV Amsterdam, Netherlands.
| | - Joop van den Bergh
- Department of Internal Medicine, VieCuri Medisch Cenrum, Tegelseweg 210, 5912 BL Venlo, Netherlands.
| |
Collapse
|
22
|
Curtis EM, Dennison EM, Cooper C, Harvey NC. Osteoporosis in 2022: Care gaps to screening and personalised medicine. Best Pract Res Clin Rheumatol 2022; 36:101754. [PMID: 35691824 PMCID: PMC7614114 DOI: 10.1016/j.berh.2022.101754] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment, and a range of effective pharmacological agents. However, it is apparent that both in the context of primary and secondary fracture prevention, there is a considerable gap between the population at high fracture risk and those actually receiving appropriate antiosteoporosis treatment. In this narrative review article, we document recent work describing the burden of disease, approaches to management, and service provision across Europe, emerging data on gaps in care, and existing/new ways in which these gaps may be addressed at the level of healthcare systems and policy. We conclude that although the field has come a long way in recent decades, there is still a long way to go, and a concerted, integrated effort is now required from all of us involved in this field to address these urgent issues to ensure the best possible outcomes for our patients.
Collapse
Affiliation(s)
- Elizabeth M Curtis
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Elaine M Dennison
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospitals Southampton NHS Foundation Trust, Southampton, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospitals Southampton NHS Foundation Trust, Southampton, UK.
| |
Collapse
|
23
|
Luo W, Chen Z, Zhang Q, Lei B, Chen Z, Fu Y, Guo P, Li C, Ma T, Liu J, Ding Y. Osteoporosis Diagnostic Model Using a Multichannel Convolutional Neural Network Based on Quantitative Ultrasound Radiofrequency Signal. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1590-1601. [PMID: 35581115 DOI: 10.1016/j.ultrasmedbio.2022.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 04/06/2022] [Accepted: 04/10/2022] [Indexed: 06/15/2023]
Abstract
Quantitative ultrasound (QUS) is a promising screening method for osteoporosis. In this study, a new method to improve the diagnostic accuracy of QUS was established in which a multichannel convolutional neural network (MCNN) processes the raw radiofrequency (RF) signal of QUS. The improvement in the diagnostic accuracy of osteoporosis using this new method was evaluated by comparison with the conventional speed of sound (SOS) method. Dual-energy X-ray absorptiometry was used as the diagnostic standard. After being trained, validated and tested in a data set consisting of 274 participants, the MCNN model could significantly raise the accuracy of osteoporosis diagnosis compared with the SOS method. The adjusted MCNN model performed even better when adjusted by age, height and weight data. The sensitivity, specificity and accuracy of the adjusted MCNN method for osteoporosis diagnosis were 80.86%, 84.23% and 83.05%, respectively; the corresponding values for SOS were 50.60%, 73.68% and 66.67%. The area under the receiver operating characteristic curve of the adjusted MCNN method was also higher than that of SOS (0.846 vs. 0.679). In conclusion, our study indicates that the MCNN method may be more accurate than the conventional SOS method. The MCNN tool and ultrasound RF signal analysis are promising future developmental directions for QUS in screening for osteoporosis.
Collapse
Affiliation(s)
- Wenqiang Luo
- Department of Orthopedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Bioland Laboratory, Guangzhou, China.
| | - Zhiwei Chen
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
| | - Qi Zhang
- Paul C. Lauterbur Research Center for Biomedical Imaging, Key Laboratory for Magnetic Resonance and Multimodality Imaging of Guangdong Province, Shenzhen Key Laboratory of Ultrasound Imaging and Therapy, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Baiying Lei
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
| | - Zhong Chen
- Department of Orthopedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuan Fu
- Department of Orthopedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Peidong Guo
- Department of Orthopedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Changchuan Li
- Department of Orthopedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Teng Ma
- Paul C. Lauterbur Research Center for Biomedical Imaging, Key Laboratory for Magnetic Resonance and Multimodality Imaging of Guangdong Province, Shenzhen Key Laboratory of Ultrasound Imaging and Therapy, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.
| | - Jiang Liu
- Cixi Institute of Biomedical Engineering, Ningbo Institute of Industrial Technology, Chinese Academy of Sciences, Ningbo, China; Department of Computer Science and Engineering, Southern University of Science and Technology, Shenzhen, China.
| | - Yue Ding
- Department of Orthopedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Bioland Laboratory, Guangzhou, China.
| |
Collapse
|
24
|
McCloskey EV, Chotiyarnwong P, Harvey NC, Lorentzon M, Kanis JA. Population screening for fracture risk in postmenopausal women - a logical step in reducing the osteoporotic fracture burden? Osteoporos Int 2022; 33:1631-1637. [PMID: 35763073 DOI: 10.1007/s00198-022-06419-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/03/2022] [Indexed: 01/05/2023]
Affiliation(s)
- E V McCloskey
- Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK.
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
| | - P Chotiyarnwong
- Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - M Lorentzon
- University of Gothenburg, Gothenburg, Sweden
- Australian Catholic University, Melbourne, Australia
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Australian Catholic University, Melbourne, Australia
| |
Collapse
|
25
|
Souliotis K, Golna C, Golnas P, Markakis IA, Makras P. To screen or not to screen for osteoporosis amongst post-menopausal women with one prior osteoporotic fracture in Greece. Aging Clin Exp Res 2022; 34:2473-2481. [PMID: 35819748 DOI: 10.1007/s40520-022-02183-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Screening and linkage to care (SLTC) for osteoporosis is suboptimal in several settings. In Greece, it is estimated that only up to 8.6% of postmenopausal women are SLTC for osteoporosis, despite having suffered a previous fracture. AIMS This study aims to estimate the impact of comprehensive screening on future fracture burden amongst post-menopausal women aged 50-74, with one prior osteoporotic fracture, in Greece. METHODS We developed a cohort stochastic model, based on published epidemiological and clinical data, to assess impact of screening on future fracture burden in two scenarios: a current, assuming an 8.6% background SLTC, and a completely hypothetical, assuming 100% SLTC. RESULTS Amongst a cohort of 50,000 post-menopausal women aged 50-74, with one prior osteoporotic fracture, applying the hypothetical versus the current scenario would result in a reduction in deaths (-0.6%) and fractures (-4.3%) over 10 years. The hypothetical scenario leads to greater reductions in costs associated with vertebral (-8.1%) and hip (-5.5%) fractures, followed by other non-vertebral (-3.0%) and forearm (-2.5%) fractures. In the hypothetical scenario, treatment initiations and total screenings increased almost tenfold versus the current scenario, at an estimated direct incremental cost of 27.83€ per woman per year in the cohort. DISCUSSION Our study adds to the existing evidence on the impact of screening to prevent fractures amongst post-menopausal women. Despite being based on a stochastic model, our study confirms findings most recently published in the literature. CONCLUSIONS Our study models the positive public health impact of increasing SLTC levels amongst post-menopausal women with a prior osteoporotic fracture.
Collapse
Affiliation(s)
- Kyriakos Souliotis
- Department of Social and Education Policy, University of Peloponnese, Corinth, Greece. .,The Health Policy Institute, Maroussi, Greece.
| | | | - Paul Golnas
- The Health Policy Institute, Maroussi, Greece
| | | | - Polyzois Makras
- Department of Endocrinology and Diabetes and Department of Medical Research, 251 Hellenic Air Force and VA General Hospital, Athens, Greece
| |
Collapse
|
26
|
Leslie WD, Möller S, Skjødt MK, Yan L, Abrahamsen B, Lix LM, McCloskey EV, Johansson H, Harvey NC, Kanis JA, Rubin KH. FREM predicts 10-year incident fracture risk independent of FRAX® probability: a registry-based cohort study. Osteoporos Int 2022; 33:1457-1463. [PMID: 35175395 DOI: 10.1007/s00198-022-06349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/13/2022] [Indexed: 10/19/2022]
Abstract
The Danish Fracture Risk Evaluation Model (FREM) was found to predict fracture risk independent of 10-year fracture probability derived with the FRAX® tool including bone mineral density from DXA. INTRODUCTION FREM was developed from Danish public health registers without DXA information to identify high imminent risk of major osteoporotic fracture (MOF) and hip fracture (HF), while FRAX® estimates 10-year fracture probability from clinical risk factors and femoral neck bone mineral density (BMD) from DXA. The FREM algorithm showed significant 1- and 2-year fracture risk stratification when applied to a clinical population from Manitoba, Canada. We examined whether FREM predicts 10-year fracture risk independent of 10-year FRAX probability computed with BMD. METHODS Using the Manitoba BMD Program registry, we identified women and men aged ≥ 45 years undergoing baseline BMD assessment. We calculated FREM and FRAX scores, and identified incident fractures over 10 years. Hazard ratios (HRs) for incident fracture were estimated according to FREM quintile, adjusted for FRAX probability. We compared predicted with observed 10-year cumulative fracture probability estimated with competing mortality. RESULTS The study population comprised 74,446 women, mean age 65.2 years; 7945 men, mean age 67.5 years. There were 7957 and 646 incident MOF and 2554 and 294 incident HF in women and men, respectively. Higher FREM scores were associated with increased risk for MOF (highest vs middle quintile HRs 1.49 women, 2.06 men) and HF (highest vs middle quintile HRs 2.15 women, 2.20 men) even when adjusted for FRAX. Greater mortality with higher FREM scores attenuated its effect on 10-year fracture probability. In the highest FREM quintile, observed slightly exceeded predicted 10-year probability for MOF (ratios 1.05 in women, 1.49 in men) and HF (ratios 1.29 in women, 1.34 in men). CONCLUSIONS Higher FREM scores identified women and men at increased fracture risk even when adjusted for FRAX probability that included BMD; hence, FREM provides additional predictive information to FRAX. FRAX slightly underestimated 10-year fracture probability in those falling within the highest FREM quintile.
Collapse
Affiliation(s)
- William D Leslie
- Department of Medicine, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.
| | - Sören Möller
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN-Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Michael K Skjødt
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Lin Yan
- Department of Medicine, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
| | - Bo Abrahamsen
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Katrine Hass Rubin
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN-Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| |
Collapse
|
27
|
LeBlanc ES, Hovey KM, Cauley JA, Stefanick M, Peragallo R, Naughton MJ, Andrews CA, Crandall CJ. Cumulative Endogenous Estrogen Exposure Is Associated With Postmenopausal Fracture Risk: The Women's Health Initiative Study. J Bone Miner Res 2022; 37:1260-1269. [PMID: 35644990 PMCID: PMC9283335 DOI: 10.1002/jbmr.4613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/09/2022] [Accepted: 05/19/2022] [Indexed: 11/11/2022]
Abstract
We aimed to evaluate the relationship between cumulative endogenous estrogen exposure and fracture risk in 150,682 postmenopausal women (aged 50 to 79 years at baseline) who participated in the Women's Health Initiative. We hypothesized that characteristics indicating lower cumulative endogenous estrogen exposure would be associated with increased fracture risk. We determined ages at menarche and menopause as well as history of irregular menses from baseline questionnaires and calculated years of endogenous estrogen exposure from ages at menarche and menopause. Incident clinical fractures were self-reported over an average 16.7 years of follow-up. We used multivariable proportional hazards models to assess the associations between the estrogen-related variables and incidence of any clinical fracture. In fully adjusted models, those with the fewest years of endogenous estrogen exposure (<30) had an 11% higher risk of developing central body fractures and a 9% higher risk of lower extremity fractures than women with 36 to 40 years of endogenous estrogen exposure (the reference category). In contrast, women with the most years of endogenous estrogen exposure (more than 45 years) had a 9% lower risk of lower extremity fractures than the reference category. Women with irregular (not monthly) menstrual cycles were 7% to 8% more likely to experience lower extremity fractures than women with regular monthly cycles. Our findings support the hypothesis that characteristics signifying lower cumulative endogenous estrogen exposure are associated with higher fracture risk. © 2022 American Society for Bone and Mineral Research (ASBMR).
Collapse
Affiliation(s)
- Erin S LeBlanc
- Kaiser Permanente, Center for Health Research, Portland, OR, USA
| | - Kathleen M Hovey
- Department of Epidemiology and Environmental Health, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marcia Stefanick
- Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Rachel Peragallo
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michelle J Naughton
- Division of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Christopher A Andrews
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn J Crandall
- Department of Internal Medicine, David Geffen School of Medicine at University of California, Los Angeles Division of General Internal Medicine and Health Services Research, Los Angeles, CA, USA
| |
Collapse
|
28
|
Chotiyarnwong P, McCloskey EV, Harvey NC, Lorentzon M, Prieto-Alhambra D, Abrahamsen B, Adachi JD, Borgström F, Bruyere O, Carey JJ, Clark P, Cooper C, Curtis EM, Dennison E, Diaz-Curiel M, Dimai HP, Grigorie D, Hiligsmann M, Khashayar P, Lewiecki EM, Lips P, Lorenc RS, Ortolani S, Papaioannou A, Silverman S, Sosa M, Szulc P, Ward KA, Yoshimura N, Kanis JA. Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group. Arch Osteoporos 2022; 17:87. [PMID: 35763133 PMCID: PMC9239944 DOI: 10.1007/s11657-022-01117-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 02/03/2023]
Abstract
The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures. INTRODUCTION The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture. METHODS The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized. RESULTS AND CONCLUSION The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.
Collapse
Affiliation(s)
- P Chotiyarnwong
- Department of Oncology & Metabolism, Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - E V McCloskey
- Department of Oncology & Metabolism, Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK.
- Centre for Metabolic Bone Diseases, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK.
| | - N C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - M Lorentzon
- University of Gothenburg, Gothenburg, Sweden
- Australian Catholic University, Melbourne, Australia
| | - D Prieto-Alhambra
- Oxford NIHR Biomedical Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
- GREMPAL (Grup de Recerca en Malalties Prevalents de L'Aparell Locomotor) Research Group, CIBERFes and Idiap Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona and Instituto de Salud Carlos III, Gran Via de Les Corts Catalanes, 591 Atico, 08007, Barcelona, Spain
| | - B Abrahamsen
- Department of Clinical Research, Odense Patient Data Exploratory Network, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - J D Adachi
- Department of Medicine, Michael G DeGroote School of Medicine, St Joseph's Healthcare-McMaster University, Hamilton, ON, Canada
| | - F Borgström
- Quantify Research, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - O Bruyere
- WHO Collaborating Center for Public Health Aspects of Musculo-Skeletal Health and Ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - J J Carey
- School of Medicine, National University of Ireland Galway, Galway, Ireland
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - P Clark
- Clinical Epidemiology Unit of Hospital Infantil de México Federico Gómez-Faculty of Medicine, Universidad Nacional Autónoma de México, UNAM, Mexico City, Mexico
| | - C Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - E M Curtis
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - E Dennison
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - M Diaz-Curiel
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - H P Dimai
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - D Grigorie
- Carol Davila University of Medicine, Bucharest, Romania
- Department of Endocrinology & Bone Metabolism, National Institute of Endocrinology, Bucharest, Romania
| | - M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - P Khashayar
- Center for Microsystems Technology, Imec and Ghent University, 9050, Ghent, Belgium
| | - E M Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - P Lips
- Department of Internal Medicine, Endocrine Section & Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - R S Lorenc
- Multidisciplinary Osteoporosis Forum, SOMED, Warsaw, Poland
| | - S Ortolani
- IRCCS Istituto Auxologico, UO Endocrinologia E Malattie del Metabolismo, Milano, Italy
| | - A Papaioannou
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- GERAS Centre for Aging Research, Hamilton, ON, Canada
| | - S Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - M Sosa
- Bone Metabolic Unit, University of Las Palmas de Gran Canaria, Hospital University Insular, Las Palmas, Gran Canaria, Spain
| | - P Szulc
- INSERM UMR 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - K A Ward
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - N Yoshimura
- Department of Preventive Medicine for Locomotive Organ Disorders, 22Nd Century Medical and Research Center, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - J A Kanis
- Centre for Metabolic Bone Diseases, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK
- Australian Catholic University, Melbourne, Australia
| |
Collapse
|
29
|
Gregson CL, Armstrong DJ, Bowden J, Cooper C, Edwards J, Gittoes NJL, Harvey N, Kanis J, Leyland S, Low R, McCloskey E, Moss K, Parker J, Paskins Z, Poole K, Reid DM, Stone M, Thomson J, Vine N, Compston J. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2022; 17:58. [PMID: 35378630 PMCID: PMC8979902 DOI: 10.1007/s11657-022-01061-5] [Citation(s) in RCA: 137] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/03/2022] [Indexed: 02/03/2023]
Abstract
The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management. INTRODUCTION The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. METHODS Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. RESULTS Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement. CONCLUSION The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.
Collapse
Affiliation(s)
- Celia L Gregson
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.
- Royal United Hospital NHS Foundation Trust, Bath, UK.
| | - David J Armstrong
- Western Health and Social Care Trust (NI), Nutrition Innovation Centre for Food and Health, Ulster University, and Visiting Professor, Belfast, Northern Ireland
| | - Jean Bowden
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John Edwards
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, and Wolstanton Medical Centre, Newcastle under Lyme, UK
| | - Neil J L Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Queen Elizabeth Hospital, University Hospitals Birmingham & University of Birmingham, Birmingham, UK
| | - Nicholas Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia and Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | | | - Rebecca Low
- Abingdon and Specialty Doctor in Metabolic Bone Disease, Marcham Road Health Centre, Nuffield Orthopaedic Centre, Oxford, UK
| | - Eugene McCloskey
- Department of Oncology & Metabolism, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - Katie Moss
- St George's University Hospital, London, UK
| | - Jane Parker
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Zoe Paskins
- School of Medicine, Keele University, Keele, Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
| | - Kenneth Poole
- Department of Medicine, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Mike Stone
- University Hospital Llandough, Cardiff and Vale University Health Board, Llandough, UK
| | | | - Nic Vine
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Juliet Compston
- University of Cambridge, School of Clinical Medicine, Cambridge, UK
| |
Collapse
|
30
|
Reid IR, Billington EO. Drug therapy for osteoporosis in older adults. Lancet 2022; 399:1080-1092. [PMID: 35279261 DOI: 10.1016/s0140-6736(21)02646-5] [Citation(s) in RCA: 187] [Impact Index Per Article: 93.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/14/2021] [Accepted: 11/11/2021] [Indexed: 02/07/2023]
Abstract
The goal of osteoporosis management is to prevent fractures. Several pharmacological agents are available to lower fracture risk, either by reducing bone resorption or by stimulating bone formation. Bisphosphonates are the most widely used anti-resorptives, reducing bone turnover markers to low premenopausal concentrations and reducing fracture rates (vertebral by 50-70%, non-vertebral by 20-30%, and hip by ~40%). Bisphosphonates bind avidly to bone mineral and have an offset of effect measured in months to years. Long term, continuous use of oral bisphosphonates is usually interspersed with drug holidays of 1-2 years, to minimise the risk of atypical femoral fractures. Denosumab is a monoclonal antibody against RANKL that potently inhibits osteoclast development and activity. Denosumab is administered by subcutaneous injection every 6 months. Anti-fracture effects of denosumab are similar to those of the bisphosphonates, but there is a pronounced loss of anti-resorptive effect from 7 months after the last injection, which can result in clusters of rebound vertebral fractures. Two classes of anabolic drugs are now available to stimulate bone formation. Teriparatide and abaloparatide both target the parathyroid hormone-1 receptor, and are given by daily subcutaneous injection for up to 2 years. Romosozumab is an anti-sclerostin monoclonal antibody that stimulates bone formation and inhibits resorption. Romosozumab is given as monthly subcutaneous injections for 1 year. Head-to-head studies suggest that anabolic agents have greater anti-fracture efficacy and produce larger increases in bone density than anti-resorptive drugs. The effects of anabolic agents are transient, so transition to anti-resorptive drugs is required. The optimal strategy for cycling anabolics, anti-resorptives, and off-treatment periods remains to be determined.
Collapse
Affiliation(s)
- Ian R Reid
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Auckland District Health Board, Auckland, New Zealand.
| | - Emma O Billington
- Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
31
|
McCloskey EV, Harvey NC, Johansson H, Lorentzon M, Liu E, Vandenput L, Leslie WD, Kanis JA. Fracture risk assessment by the FRAX model. Climacteric 2022; 25:22-28. [PMID: 34319212 DOI: 10.1080/13697137.2021.1945027] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
The introduction of the FRAX algorithms has facilitated the assessment of fracture risk on the basis of fracture probability. FRAX integrates the influence of several well-validated risk factors for fracture with or without the use of bone mineral density. Since age-specific rates of fracture and death differ across the world, FRAX models are calibrated with regard to the epidemiology of hip fracture (preferably from national sources) and mortality (usually United Nations sources). Models are currently available for 73 nations or territories covering more than 80% of the world population. FRAX has been incorporated into more than 80 guidelines worldwide, although the nature of this application has been heterogeneous. The limitations of FRAX have been extensively reviewed. Arithmetic procedures have been proposed in order to address some of these limitations, which can be applied to conventional FRAX estimates to accommodate knowledge of dose exposure to glucocorticoids, concurrent data on lumbar spine bone mineral density, information on trabecular bone score, hip axis length, falls history, type 2 diabetes, immigration status and recency of prior fracture.
Collapse
Affiliation(s)
- E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Centre for Integrated research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, VIC, Australia
| | - M Lorentzon
- Centre for Bone and Arthritis Research (CBAR), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Sweden
| | - E Liu
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, VIC, Australia
| | - L Vandenput
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, VIC, Australia
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Sweden
| | - W D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, VIC, Australia
| |
Collapse
|
32
|
Lorentzon M, Johansson H, Harvey NC, Liu E, Vandenput L, McCloskey EV, Kanis JA. Osteoporosis and fractures in women: the burden of disease. Climacteric 2022; 25:4-10. [PMID: 34319208 DOI: 10.1080/13697137.2021.1951206] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/17/2021] [Indexed: 01/09/2023]
Abstract
Osteoporosis is a disease characterized by impaired bone microarchitecture and reduced bone mineral density (BMD) resulting in bone fragility and increased risk of fracture. In western societies, one in three women and one in five men will sustain an osteoporotic fracture in their remaining lifetime from the age of 50 years. Fragility fractures, especially of the spine and hip, commonly give rise to increased morbidity and mortality. In the five largest European countries and Sweden, fragility fractures were the cause of 2.6 million disability-adjusted life years in 2016 and the fracture-related costs increased from €29.6 billion in 2010 to €37.5 billion in 2017. In the European Union and the USA, only a small proportion of women eligible for pharmacological treatment are being prescribed osteoporosis medication. Secondary fracture prevention, using Fracture Liaison Services, can be used to increase the rates of fracture risk assessment, BMD testing and use of osteoporosis medication in order to reduce fracture numbers. Additionally, established primary prevention strategies, based on case-finding methods utilizing fracture prediction tools, such as FRAX, to identify women without fracture but with elevated risk, are recommended in order to further reduce fracture numbers.
Collapse
Affiliation(s)
- M Lorentzon
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - H Johansson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - E Liu
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - L Vandenput
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - J A Kanis
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| |
Collapse
|
33
|
Sun X, Chen Y, Gao Y, Zhang Z, Qin L, Song J, Wang H, Wu IXY. Prediction Models for Osteoporotic Fractures Risk: A Systematic Review and Critical Appraisal. Aging Dis 2022; 13:1215-1238. [PMID: 35855348 PMCID: PMC9286920 DOI: 10.14336/ad.2021.1206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/06/2021] [Indexed: 11/01/2022] Open
Abstract
Osteoporotic fractures (OF) are a global public health problem currently. Many risk prediction models for OF have been developed, but their performance and methodological quality are unclear. We conducted this systematic review to summarize and critically appraise the OF risk prediction models. Three databases were searched until April 2021. Studies developing or validating multivariable models for OF risk prediction were considered eligible. Used the prediction model risk of bias assessment tool to appraise the risk of bias and applicability of included models. All results were narratively summarized and described. A total of 68 studies describing 70 newly developed prediction models and 138 external validations were included. Most models were explicitly developed (n=31, 44%) and validated (n=76, 55%) only for female. Only 22 developed models (31%) were externally validated. The most validated tool was Fracture Risk Assessment Tool. Overall, only a few models showed outstanding (n=3, 1%) or excellent (n=32, 15%) prediction discrimination. Calibration of developed models (n=25, 36%) or external validation models (n=33, 24%) were rarely assessed. No model was rated as low risk of bias, mostly because of an insufficient number of cases and inappropriate assessment of calibration. There are a certain number of OF risk prediction models. However, few models have been thoroughly internally validated or externally validated (with calibration being unassessed for most of the models), and all models showed methodological shortcomings. Instead of developing completely new models, future research is suggested to validate, improve, and analyze the impact of existing models.
Collapse
Affiliation(s)
- Xuemei Sun
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Yancong Chen
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Yinyan Gao
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Zixuan Zhang
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Lang Qin
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Jinlu Song
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Huan Wang
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Irene XY Wu
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha 410000, China
- Correspondence should be addressed to: Dr. IXY Wu, Xiangya School of Public health, Central South University, Xiangya School of Public health, Changsha 410000, Hunan, China.
| |
Collapse
|
34
|
Seaman AT, Steffen MJA, Van Tiem JM, Wardyn S, Santana X, Miller KL, Solimeo SL. Cultivating across "pockets of excellence": challenges to sustaining efforts to improve osteoporosis care. Osteoporos Int 2022; 33:139-147. [PMID: 34414462 DOI: 10.1007/s00198-021-06098-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/13/2021] [Indexed: 12/01/2022]
Abstract
UNLABELLED We conducted in-depth, semi-structured interviews with clinicians involved in bone health care to understand the challenges of implementing and sustaining bone health care interventions. Participants identified individual- and system-level challenges to care delivery, implementation, and sustainment. We discuss opportunities to address challenges through a commitment to relationship- and infrastructure-building support. PURPOSE Osteoporosis and fracture-related sequalae exact significant individual and societal costs; however, identification and treatment of at-risk patients are troublingly low, especially among men. The purpose of this study was to identify challenges to implementing and sustaining bone health care delivery interventions in the Veterans Health Administration. METHODS We conducted interviews with endocrinologists, pharmacists, primary care physicians, rheumatologists, and orthopedic surgeons involved in bone health care (n = 20). Interviews were audio-recorded and transcribed verbatim. To determine thematic domains, we engaged in an iterative, qualitative content analysis of the transcripts. RESULTS Participants reported multiple barriers to delivering bone health care and to sustaining the initiatives designed to address delivery challenges. Challenges of bone health care delivery existed at both the individual level-a lack of patient and clinician awareness and competing clinical demands-and the system level-multiple points of entry to bone health care, a dispersion of patient management, and guideline variability. To address the challenges, participants developed initiatives targeting the identification of at-risk patients, clinician education, increasing communication, and care coordination. Sustaining initiatives, however, was challenged by staff turnover and the inability to achieve and maintain priority status for bone health care. CONCLUSION The multiple, multi-level barriers to bone health care affect both care delivery processes and sustainment of initiatives to improve those processes. Barriers to care delivery, while tempered by intervention, are entangled and persist alongside sustainment challenges. These challenges require relationship- and infrastructure-building support.
Collapse
Affiliation(s)
- Aaron T Seaman
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA.
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA.
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 280-B MRF, USA.
| | - Melissa J A Steffen
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Jennifer M Van Tiem
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Shylo Wardyn
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Xiomara Santana
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Karla L Miller
- VA Office of Rural Health Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT, USA
- Department of Internal Medicine, Rheumatology Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Samantha L Solimeo
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 280-B MRF, USA
- Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
| |
Collapse
|
35
|
Tanha K, Fahimfar N, Nematollahi S, Sajjadi-Jazi SM, Gharibzadeh S, Sanjari M, Khalagi K, Hajivalizedeh F, Raeisi A, Larijani B, Ostovar A. Annual incidence of osteoporotic hip fractures in Iran: a systematic review and meta-analysis. BMC Geriatr 2021; 21:668. [PMID: 34847861 PMCID: PMC8638533 DOI: 10.1186/s12877-021-02603-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background Osteoporosis (OP) is progressively becoming a global concern with the aging of the world’s populations. Osteoporotic fractures are associated with significantly increased mortality rates and a financial burden to health systems. This Meta-analysis aims to estimate the annual incidence of osteoporotic fractures in Iran. Methods A comprehensive systematic literature search was performed through Medline (PubMed), Embase, Scopus, Web of Science, and Google Scholar to identify studies which contain an investigation of the incidence of osteoporotic fractures in Iran up to December 3rd 2020, with no time and language restriction. For the risk of bias assessments of studies, the Joanna Briggs Institute (JBI) critical appraisal checklist for studies reporting prevalence data was used. The pooled estimation of the incidence of osteoporotic fractures in population aged≥50 years was calculated using random-effects meta-analysis, and the heterogeneity of included studies was quantified with the I2 statistic. Results In all, 6708 papers were initially retrieved from the electronic databases, among which seven studies were included in the meta-analysis. The pooled standardized annual cumulative incidence of hip fractures was estimated as 138.26 (95% CI: 98.71–193.65) per 100,000 population and 157.52 (95% CI: 124.29–199.64) per 100,000 population in men and women, respectively. Conclusion This study showed a high incidence rate of osteoporotic hip fractures in Iran. Early detection and treatment of individuals with higher risks of primary fragility fractures at primary health care as well as implementing fracture liaison services to prevent secondary fractures are highly recommended. The results suffer from the following limitations: first, a low number of studies that were eligible for inclusion; second, the lack of population-based studies; and presence of highly heterogeneous studies despite the use of a random effect model. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02603-1.
Collapse
Affiliation(s)
- Kiarash Tanha
- Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran.,Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Noushin Fahimfar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Shahrzad Nematollahi
- Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sayed Mahmoud Sajjadi-Jazi
- Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Safoora Gharibzadeh
- Department of Epidemiology and Biostatistics, Pasteur Institute of Iran, Tehran, Iran
| | - Mahnaz Sanjari
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Khalagi
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Alireza Raeisi
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Afshin Ostovar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
36
|
Chandran M, Kwee A. Treatment indications and thresholds of intervention: consensus and controversies in osteoporosis. Climacteric 2021; 25:29-36. [PMID: 34313165 DOI: 10.1080/13697137.2021.1951205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A few indications for treatment and thresholds for intervention in osteoporosis have been propounded in the literature and recommended in guidelines. These include a bone mineral density (BMD) T-score ≤ -2.5, fracture probability-based scores and the presence of a fragility fracture. A low BMD is associated with an increased risk of fracture. However, a BMD T-score of ≤ -2.5 on its own does not capture fracture risk in its entirety. Fracture risk assessment tools that are based on clinical risk factors arose from the misgivings about using BMD T-scores in isolation to assess fracture risk. Algorithms such as FRAX, Garvan etc, integrate various clinical risk factors with or without BMD to compute the probability of a hip fracture or a major osteoporotic fracture over a finite period. These probabilities do not yield distinctive thresholds by themselves and need to be interpreted wisely and adopted by consensus. Evidence exists to show that treatment can decrease the risk of sustaining a second fracture. Therefore, patients with a fragility fracture should be considered for treatment. In this narrative interview, we will explore the strengths and limitations of some of these indications for treatment and will discuss the various points of contention surrounding them.
Collapse
Affiliation(s)
- M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - A Kwee
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|
37
|
Sarcopenia and Malnutrition Screening in Female Osteoporosis Patients-A Cross-Sectional Study. J Clin Med 2021; 10:jcm10112344. [PMID: 34071858 PMCID: PMC8198508 DOI: 10.3390/jcm10112344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 11/17/2022] Open
Abstract
Sarcopenia and malnutrition are important determinants of increased fracture risk in osteoporosis. SARC-F and MNA-SF are well-established questionnaires for identifying patients at risk for these conditions. We sought to evaluate the feasibility and potential added benefit of such assessments as well as the actual prevalence of these conditions in osteoporosis patients. We conducted a cross-sectional, single-center study in female osteoporosis patients ≥ 65 years (SaNSiBaR-study). Results of the sarcopenia (SARC-F) and malnutrition (MNA-SF) screening questionnaires were matched with a functional assessment for sarcopenia and data from patients’ medical records. Out of 107 patients included in the analysis, a risk for sarcopenia (SARC-F ≥ 4 points) and a risk for malnutrition (MNA-SF ≤ 11 points) was found in 33 (30.8%) and 38 (35.5%) patients, respectively. Diagnostic overlap with coincident indicative findings in both questionnaires was observed in 17 patients (16%). As compared to the respective not-at-risk groups, the mean short physical performance battery (SPPB) score was significantly reduced in both patients at risk for sarcopenia (7.0 vs. 10.9 points, p < 0.001) and patients at risk for malnutrition (8.7 vs. 10.5 points, p = 0.005). Still, confirmed sarcopenia according to EWGSOP2 criteria was present in only 6 (6%) of all 107 patients, with only 3 of them having an indicative SARC-F score. Bone mineral density was not significantly different in any of the at-risk groups at any site. In summary, applying SARC-F and MNA-SF in osteoporosis patients appears to be a complementary approach to identify individuals with functional deficits.
Collapse
|
38
|
Filippini DM, Gatti M, Di Martino V, Cavalieri S, Fusaroli M, Ardizzoni A, Raschi E, Licitra L. Bone fracture as a novel immune-related adverse event with immune checkpoint inhibitors: Case series and large-scale pharmacovigilance analysis. Int J Cancer 2021; 149:675-683. [PMID: 33844854 PMCID: PMC8251715 DOI: 10.1002/ijc.33592] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/07/2021] [Accepted: 03/29/2021] [Indexed: 12/19/2022]
Abstract
Although immune checkpoint inhibitors (ICIs) are associated with different immune-related adverse events (irAEs), the potential effect on the skeleton is poorly defined albeit biologically plausible and assessable through pharmacovigilance. We described a case series of patients experiencing skeletal fractures while on ICIs at the National Cancer Institute of Milan. To better characterize the clinical features of skeletal irAEs reported with ICIs, we queried the FDA Adverse Event Reporting System (FAERS) and performed disproportionality analysis by means of reporting odds ratios (RORs), deemed significant by a lower limit of the 95% confidence interval (LL95% CI) > 1. Bone AEs emerging as significant were scrutinized in terms of demographic and clinical data, including concomitant irAEs or drugs affecting bone resorption or causing bone damage. Four patients with skeletal events while on ICIs were included in our case series, of which three exhibited vertebral fractures. In FAERS, 650 patients with bone and joint injuries and treated with ICIs were retrieved, accounting for 822 drug-event pairs. Statistically significant ROR was found for eight, two and one bone AEs respectively with PD-1, PD-L1 and CTLA-4 inhibitors, being pathological fracture (N = 46; ROR = 3.17; LL95%CI = 2.37), spinal compression fracture (42; 2.51; 1.91), and femoral neck fracture (26; 2.38; 1.62) the most common. Concomitant irAEs or drugs affecting bone metabolism were poorly reported. The increased reporting of serious vertebral fractures in patients without concomitant irAEs and no apparent preexisting risk factors could suggest a possible cause-effect relationship and calls for close clinical monitoring and implementation of dedicated guidelines.
Collapse
Affiliation(s)
- Daria Maria Filippini
- Head and Neck Medical Oncology Unit, Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.,Medical Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Milo Gatti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Vito Di Martino
- Head and Neck Medical Oncology Unit, Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Cavalieri
- Head and Neck Medical Oncology Unit, Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan, Italy
| | - Michele Fusaroli
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Andrea Ardizzoni
- Medical Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Lisa Licitra
- Head and Neck Medical Oncology Unit, Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan, Italy
| |
Collapse
|
39
|
Pouillès JM, Gosset A, Trémollieres F. [Menopause, menopause hormone therapy and osteoporosis. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2021; 49:420-437. [PMID: 33753297 DOI: 10.1016/j.gofs.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Postmenopausal osteoporosis is a frequent clinical condition, which affects nearly 1 in 3 women. Estrogen deficiency leads to rapid bone loss, which is maximal within the first years after the menopause transition and can be prevented by menopause hormone therapy (MHT). Assessment of the individual risk of osteoporosis is primarily based on the measurement of bone mineral density (BMD) at the spine and femur by DXA. Clinical risk factors (CRFs) for fractures taken either alone or in combination in the FRAX score were shown not to reliably predict fractures and/or osteoporosis (as defined by a T-score<-2.5) in early postmenopausal women. If DXA measurement is indicated in all women with CRFs for fractures, it can be proposed on a case-by-case basis, when knowledge of BMD is likely to condition the management of women at the beginning of menopause, particularly the benefit-risk balance of MHT. MHT prevents both bone loss and degradation of the bone microarchitecture in early menopause. It significantly reduces the risk of fracture at all bone sites by 20 to 40% regardless of basal level of risk with an estrogen-dependent dose-effect. Given the inter-individual variability in bone response, individual monitoring of the bone effect of MHT is warranted when prescribed for the prevention of osteoporosis. This monitoring is based on repeated measurement of lumbar and femoral BMD (on the same DXA measurement system) after 2years of MHT, the response criterion being no significant bone loss. Discontinuation of treatment is associated with a resumption of transient bone loss although there is a large variability in the rate of bone loss among women. Basically, there is a return to the level of fracture risk comparable to that of in untreated woman of the same age within 2 to 5years. Therefore, when MHT is prescribed for the prevention of osteoporosis in women with an increased risk at the beginning of menopause, measurement of BMD is recommended when MHT is stopped in order to consider further management of the risk of fracture whenever necessary (with possibly another anti-osteoporotic treatment).
Collapse
Affiliation(s)
- J-M Pouillès
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule-de-Viguier, CHU Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse, France
| | - A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule-de-Viguier, CHU Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse, France
| | - F Trémollieres
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule-de-Viguier, CHU Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse, France; INSERM U1048, I2MC, équipe 9, université Toulouse III Paul-Sabatier, 1, avenue du Professeur-Jean-Poulhès, BP 84225, 31432 Toulouse cedex 4, France.
| |
Collapse
|
40
|
Clinical guidelines for the application of panoramic radiographs in screening for osteoporosis. Oral Radiol 2021; 37:189-208. [PMID: 33620644 DOI: 10.1007/s11282-021-00518-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/09/2021] [Indexed: 02/07/2023]
Abstract
Osteoporotic fractures are associated with an increased risk of subsequent fractures, a higher rate of mortality, and incremental medical costs. Incidental findings, which include some measurements related to the mandibular inferior cortex and the alveolar trabecular bone pattern of the mandible determined on panoramic radiographs, are considered to be a useful tool for identifying asymptomatic individuals at risk of having osteoporosis and/or fragility fractures. We undertook a worldwide literature survey and present the following clinical recommendations. Postmenopausal female dental patients with a mandibular inferior cortical width of less than 3 mm on panoramic radiographs may be at risk of having low skeletal bone mineral density (BMD) or osteoporosis, but not fragility fractures. In addition, those with a severely eroded mandibular inferior cortex may have an increased risk of having low skeletal BMD, osteoporosis, and fragility fractures. The alveolar trabecular bone pattern of the mandible might be useful for identifying female dental patients at risk of having fragility fractures, although further investigation is necessary to confirm this possibility. These incidental findings on panoramic radiographs, when used for identifying asymptomatic postmenopausal female patients at risk of having osteoporosis in general dental practice, may be helpful in reducing the incidence of first fractures, with a consequent reduction in the secondary fractures, medical costs, and mortality associated with osteoporotic fragility fractures, without incurring any additional cost.
Collapse
|
41
|
McCloskey E, Rathi J, Heijmans S, Blagden M, Cortet B, Czerwinski E, Hadji P, Payer J, Palmer K, Stad R, O'Kelly J, Papapoulos S. The osteoporosis treatment gap in patients at risk of fracture in European primary care: a multi-country cross-sectional observational study. Osteoporos Int 2021; 32:251-259. [PMID: 32829471 PMCID: PMC7838133 DOI: 10.1007/s00198-020-05557-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 07/21/2020] [Indexed: 01/15/2023]
Abstract
UNLABELLED This study in 8 countries across Europe found that about 75% of elderly women seen in primary care who were at high risk of osteoporosis-related fractures were not receiving appropriate medication. Lack of osteoporosis diagnosis appeared to be an important contributing factor. INTRODUCTION Treatment rates in osteoporosis are documented to be low. We wished to assess the osteoporosis treatment gap in women ≥ 70 years in routine primary care across Europe. METHODS This cross-sectional observational study in 8 European countries collected data from women 70 years or older visiting their general practitioner. The primary outcome was treatment gap: the proportion who were not receiving any osteoporosis medication among those at increased risk of fragility fracture (using history of fracture, 10-year probability of fracture above country-specific Fracture Risk Assessment Tool [FRAX] thresholds, T-score ≤ - 2.5). RESULTS Median 10-year probability of fracture (without bone mineral density [BMD]) for the 3798 enrolled patients was 7.2% (hip) and 16.6% (major osteoporotic). Overall, 2077 women (55%) met one or more definitions for increased risk of fragility fracture: 1200 had a prior fracture, 1814 exceeded the FRAX threshold, and 318 had a T-score ≤ - 2.5 (only 944 received a dual-energy x-ray absorptiometry [DXA] scan). In those at increased fracture risk, the median 10-year probability of hip and major osteoporotic fracture was 11.2% and 22.8%, vs 4.1% and 11.5% in those deemed not at risk. An osteoporosis diagnosis was recorded in 804 patients (21.2%); most (79.7%) of these were at increased fracture risk. The treatment gap was 74.6%, varying from 53% in Ireland to 91% in Germany. Patients with an osteoporosis diagnosis were found to have a lower treatment gap than those without a diagnosis, with an absolute reduction of 63%. CONCLUSIONS There is a large treatment gap in women aged ≥ 70 years at increased risk of fragility fracture in routine primary care across Europe. The gap appears to be related to a low rate of osteoporosis diagnosis.
Collapse
Affiliation(s)
- E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
| | - J Rathi
- Carrig Medical Centre, Cork, Ireland
| | | | - M Blagden
- Ashgate Medical Practice, Chesterfield, UK
| | - B Cortet
- Department of Rheumatology and EA 4490, University-Hospital of Lille, Lille, France
| | - E Czerwinski
- Department of Bone and Joint Diseases, FHS, Jagiellonian University Medical College, Kopernika 32, 31-501, Krakow, Poland
| | - P Hadji
- Frankfurt Center of Bone Health, Frankfurt, Germany
- Philipps-University of Marburg, Marburg, Germany
| | - J Payer
- Faculty of Medicine, 5th Department of Internal Medicine in University Hospital Bratislava, Comenius University, Bratislava, Slovakia
| | | | - R Stad
- Amgen Europe GmbH, Rotkreuz, Switzerland
| | | | - S Papapoulos
- Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
42
|
Chen X, Li J, Ye Y, Huang J, Xie L, Chen J, Li S, Chen S, Ge J. Association of cardiotrophin-like cytokine factor 1 levels in peripheral blood mononuclear cells with bone mineral density and osteoporosis in postmenopausal women. BMC Musculoskelet Disord 2021; 22:62. [PMID: 33430863 PMCID: PMC7798196 DOI: 10.1186/s12891-020-03924-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/26/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Recent research has suggested that cardiotrophin-like cytokine factor 1 (CLCF1) may be an important regulator of bone homeostasis. Furthermore, a whole gene chip analysis suggested that the expression levels of CLCF1 in the peripheral blood mononuclear cells (PBMCs) were downregulated in postmenopausal women with osteoporosis. This study aimed to assess whether the expression levels of CLCF1 in PBMCs can reflect the severity of bone mass loss and the related fracture risk. METHODS In all, 360 postmenopausal women, aged 50 to 80 years, were included in the study. A survey to evaluate the participants' health status, measurement of bone mineral density (BMD), routine blood test, and CLCF1 expression level test were performed. RESULTS Based on the participants' bone health, 27 (7.5%), 165 (45.83%), and 168 (46.67%) participants were divided into the normal, osteopenia, and osteoporosis groups, respectively. CLCF1 protein levels in the normal and osteopenia groups were higher than those in the osteoporosis group. While the CLCF1 mRNA level was positively associated with the BMD of total femur (r = 0.169, p = 0.011) and lumbar spine (r = 0.176, p = 0.001), the protein level was positively associated with the BMD of the lumbar spine (r = 0.261, p < 0.001), femoral neck (r = 0.236, p = 0.001), greater trochanter (r = 0.228, p = 0.001), and Ward's triangle (r = 0.149, p = 0.036). Both the mRNA and protein levels were negatively associated with osteoporosis development (r = - 0.085, p = 0.011 and r = - 0.173, p = 0.014, respectively). The association between CLCF1 protein level and fracture risk was not significant after adjusting for BMD. CONCLUSIONS To our knowledge, this is the first clinical study to show that CLCF1 expression levels in the PBMCs of postmenopausal women can reflect the amount of bone mass or the severity of bone mass loss.
Collapse
Affiliation(s)
- Xuan Chen
- Key Research Laboratory of Osteoporosis Syndrome Genomics, Fujian Academy of Chinese Medical Sciences, No. 282 Wusi Road, Fuzhou, 350003, Fujian, China
| | - Jianyang Li
- College of Traditional Chinese Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, 350122, China
| | - Yunjin Ye
- Key Research Laboratory of Osteoporosis Syndrome Genomics, Fujian Academy of Chinese Medical Sciences, No. 282 Wusi Road, Fuzhou, 350003, Fujian, China
| | - Jingwen Huang
- Key Research Laboratory of Osteoporosis Syndrome Genomics, Fujian Academy of Chinese Medical Sciences, No. 282 Wusi Road, Fuzhou, 350003, Fujian, China
| | - Lihua Xie
- Key Research Laboratory of Osteoporosis Syndrome Genomics, Fujian Academy of Chinese Medical Sciences, No. 282 Wusi Road, Fuzhou, 350003, Fujian, China
| | - Juan Chen
- Key Research Laboratory of Osteoporosis Syndrome Genomics, Fujian Academy of Chinese Medical Sciences, No. 282 Wusi Road, Fuzhou, 350003, Fujian, China
| | - Shengqiang Li
- Key Research Laboratory of Osteoporosis Syndrome Genomics, Fujian Academy of Chinese Medical Sciences, No. 282 Wusi Road, Fuzhou, 350003, Fujian, China
| | - Sainan Chen
- Key Research Laboratory of Osteoporosis Syndrome Genomics, Fujian Academy of Chinese Medical Sciences, No. 282 Wusi Road, Fuzhou, 350003, Fujian, China
| | - Jirong Ge
- Key Research Laboratory of Osteoporosis Syndrome Genomics, Fujian Academy of Chinese Medical Sciences, No. 282 Wusi Road, Fuzhou, 350003, Fujian, China.
| |
Collapse
|
43
|
Ito K. Cost-effectiveness of Screening for Osteoporosis in Older Men With a History of Falls. JAMA Netw Open 2020; 3:e2027584. [PMID: 33258906 PMCID: PMC7708999 DOI: 10.1001/jamanetworkopen.2020.27584] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/06/2020] [Indexed: 12/01/2022] Open
Abstract
Importance Falls and osteoporosis share the potential clinical end point of fractures among older patients. To date, few fall prevention guidelines incorporate screening for osteoporosis to reduce fall-related fractures. Objective To assess the cost-effectiveness of screening for osteoporosis using dual-energy x-ray absorptiometry (DXA) followed by osteoporosis treatment in older men with a history of falls. Design, Setting, and Participants In this economic evaluation, a Markov model was developed to simulate the incidence of major osteoporotic fractures in a hypothetical cohort of community-dwelling men aged 65 years who had fallen at least once in the past year. Data sources included literature published from January 1, 1946, to July 31, 2020. The model adopted a societal perspective, a lifetime horizon, a 1-year cycle length, and a discount rate of 3% per year for both health benefits and costs. The analysis was designed and conducted from October 1, 2019, to September 30, 2020. Interventions Screening with DXA followed by treatment for men diagnosed with osteoporosis compared with usual care. Main Outcomes and Measures Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained. Results Among the hypothetical cohort of men aged 65 years, the screening strategy had an ICER of $33 169/QALY gained and was preferred over usual care at the willingness-to-pay threshold of $100 000/QALY gained. The number needed to screen to prevent 1 hip fracture was 1876; to prevent 1 major osteoporotic fracture, 746. The screening strategy would become more effective and less costly than usual care for men 77 years and older. The ICER for the screening strategy did not substantially change across a wide range of assumptions tested in all other deterministic sensitivity analyses. At a willingness-to-pay threshold of $50 000/QALY gained, screening was cost-effective in 56.0% of simulations; at $100 000/QALY gained, 90.8% of simulations; and at $200 000/QALY gained, 99.6% of simulations. Conclusions and Relevance These findings suggest that for older men who have fallen at least once in the past year, screening with DXA followed by treatment for those diagnosed with osteoporosis is a cost-effective use of resources. Fall history could be a useful cue to trigger assessment for osteoporosis in men.
Collapse
Affiliation(s)
- Kouta Ito
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester
- Meyers Primary Care Institute, Worcester, Massachusetts
| |
Collapse
|
44
|
Choi SM, Cho SH, Kim BC. Association between freezing of gait and bone mineral density in patients with Parkinson's disease. Neurol Sci 2020; 42:2921-2925. [PMID: 33230756 DOI: 10.1007/s10072-020-04920-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/16/2020] [Indexed: 11/27/2022]
Abstract
Parkinson's disease (PD) patients are at risk for developing bone health problems, and freezing of gait (FOG) in PD is associated with a high risk of falling and fracture. This study aimed to determine the association between FOG and bone mineral density (BMD) in patients with PD. We included 148 PD patients. FOG was assessed using the FOG Questionnaire (FOG-Q), and BMD was measured by dual-energy X-ray absorptiometry. Of 148 PD patients, 102 (68.9%) had FOG. PD patients with FOG were older and had longer disease duration, higher levodopa equivalent dose, higher modified Hoehn and Yahr stage, higher Unified PD Rating Scale motor score, higher FOG-Q score, higher total Non-Motor Symptom Scale score, and lower BMD scores in the femoral neck area than those without FOG. Pearson correlation analysis revealed that age, sex, body mass index, and age at onset were significantly correlated with areal BMDs in all areas. FOG-Q scores correlated negatively with areal BMDs in the total hip area and femoral neck, but not with areal BMD in the lumbar spine. Multivariate regression analysis showed that FOG-Q score was significantly correlated with areal BMD in the femoral neck, but not with areal BMDs in the lumbar spine or total hip. FOG in PD patients correlates significantly with BMD in the femoral neck area. Therefore, PD patients with FOG should be screened for osteoporosis.
Collapse
Affiliation(s)
- Seong-Min Choi
- Department of Neurology, Chonnam National University Medical School and Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 58128, South Korea
- National Research Center for Dementia, Gwangju, South Korea
| | - Soo Hyun Cho
- Department of Neurology, Chonnam National University Medical School and Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 58128, South Korea
| | - Byeong C Kim
- Department of Neurology, Chonnam National University Medical School and Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 58128, South Korea.
- National Research Center for Dementia, Gwangju, South Korea.
| |
Collapse
|
45
|
Wilczek ML, Bhatta L, Brumpton BM, Freyschuss B, Brismar TB. Screening for women with increased risk of fragility fractures in a general female population using digital X-ray radiogrammetry (DXR). Maturitas 2020; 144:60-67. [PMID: 33358210 DOI: 10.1016/j.maturitas.2020.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/25/2020] [Accepted: 10/27/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the predictive ability of digital X-ray radiogrammetry (DXR) for fracture in women attending general mammography screening. STUDY DESIGN In a nested case-control study, women aged between 40 and 75 years, who attended the regional mammography screening program, had their bone mass assessed with DXR and provided information regarding clinical risk factors for osteoporosis. Follow-up was done through cross-referencing with National Patient Registers. Associations between DXR, clinical risk factors and fracture risk were examined. Receiver operating characteristics curves for DXR T-score and different fracture types were plotted, and their respective AUC calculated. MAIN OUTCOME MEASURES Fractures (hip, major osteoporotic and any clinical facture). Fracture diagnoses were retrieved from National Patient Registers. RESULTS 14,841 women had their bone mass examined in conjunction with mammography. Of these women, 10,967 returned fully completed questionnaires regarding clinical risk factors. In total 605 fractures (including 355 major osteoporotic fractures and 18 hip fractures) occurred during the follow-up period (median follow-up time was 3.3 years). Women with fractures were older and had lower DXR T-score compared with those without. DXR T-score correlated with fracture risk. HR/SD T-score decrease was 2.15 (CI 1.55-3.00) for hip, 1.47 (CI 1.36-1.59) for major osteoporotic and 1.33 (CI 1.26-1.42) for any clinical fracture. The AUCs for the different fracture types were 0.79 (hip), 0.69 (major osteoporotic) and 0.65 (any clinical). CONCLUSIONS DXR T-score is negatively correlated with risk of fracture in a general female population. This indicates a potential use of DXR in population-based screening for osteoporosis.
Collapse
Affiliation(s)
- M L Wilczek
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - L Bhatta
- Norwegian University of Science and Technology, NTNU, Department of Public Health and Nursing, Norway
| | - B M Brumpton
- Norwegian University of Science and Technology, NTNU, Department of Public Health and Nursing, Norway
| | - B Freyschuss
- Department of Medicine H7, Karolinska Institutet, Stockholm, Sweden
| | - T B Brismar
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
46
|
Leslie WD, Lix LM, Binkley N. Comparison of screening tools for optimizing fracture prevention in Canada. Arch Osteoporos 2020; 15:170. [PMID: 33111193 DOI: 10.1007/s11657-020-00846-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/20/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED The best screening strategy to identify treatment qualification based upon indicators of high fracture risk (low-trauma fractures of the hip, spine, or multiple fracture episodes at other sites; high fracture probability with the Canadian fracture risk assessment [FRAX®] tool major osteoporotic fracture [MOF] computed with bone mineral density [BMD] > 20%; or vertebral fracture on vertebral fracture assessment [VFA]) was FRAX-MOF without BMD using a cutoff of ≥ 10%. PURPOSE To inform clinical practice guidelines in Canada, we compared multiple screening tools using the population-based Manitoba BMD Program registry. METHODS The study populations consisted of (a) 28,906 individuals > 50 years or older, and (b) 15,429 women age > 65 years undergoing baseline BMD assessment (2010-2018). We considered two treatment qualifications: Treatment Approach 1: prior high-risk fracture, high fracture probability (FRAX-MOF with BMD > 20%), or vertebral fracture on VFA; Treatment Approach 2: Approach 1 or an osteoporotic BMD T score. Candidate screening tools were FRAX-MOF without BMD, age alone, weight alone, SCORE, ORAI, SOFSURF, OSIRIS, ABONE, and OST. Healthcare records were assessed for the presence of incident fracture diagnoses. RESULTS Among all individuals, FRAX-MOF without BMD demonstrated the best ability to identify those satisfying Treatment Approach 1 (area under the curve [AUC 0.863]) and was significantly better than all other screening tools (P < 0.001). For identification of individuals satisfying Treatment Approach 2, FRAX-MOF without BMD showed moderate stratification (AUC 0.735), slightly lower than OSIRIS (AUC 0.752, P < 0.05), similar to SCORE (AUC 0.739, P > 0.05) and significantly better than all other screening tools (P < 0.05). For prediction of incident MOF, FRAX-MOF without BMD achieved the highest performance (AUC 0.652), and was significantly better than all other screening tools except OSIRIS. AUCs among women age > 65 years tended to be greater with a similar ranking, and no tool outperformed FRAX-MOF without BMD. Based upon a summary score, the highest ranked strategy was FRAX-MOF without BMD using a cutoff of 10%. CONCLUSIONS All screening tools show some ability to identify individuals qualifying for treatment and stratify risk for incident fracture. For treatment based upon indicators of high fracture risk, the best performing strategy was FRAX-MOF without BMD using a cutoff of ≥ 10%.
Collapse
Affiliation(s)
- William D Leslie
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | |
Collapse
|
47
|
Value-Added Opportunistic CT: Insights Into Osteoporosis and Sarcopenia. AJR Am J Roentgenol 2020; 215:582-594. [DOI: 10.2214/ajr.20.22874] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
48
|
McCloskey E, Harvey N, Johansson H, Lorentzon M, Vandenput L, Kanis JA. Screening for high fracture risk. Osteoporos Int 2020; 31:1179-1180. [PMID: 32333067 DOI: 10.1007/s00198-020-05416-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/08/2020] [Indexed: 11/29/2022]
Affiliation(s)
- E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
- Centre for Integrated research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK.
- Metabolic Bone Centre, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK.
| | - N Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - M Lorentzon
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
| | - L Vandenput
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre of Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| |
Collapse
|
49
|
Merlijn T, Swart KMA, Netelenbos JC, Elders PJM. Reply to "Screening for high fracture risk". Osteoporos Int 2020; 31:1183-1184. [PMID: 32333066 DOI: 10.1007/s00198-020-05417-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Affiliation(s)
- T Merlijn
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health research institute, 1081 BT, Amsterdam, Netherlands
| | - K M A Swart
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health research institute, 1081 BT, Amsterdam, Netherlands
| | - J C Netelenbos
- Internal Medicine, Endocrine Section, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, Netherlands
| | - P J M Elders
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health research institute, 1081 BT, Amsterdam, Netherlands.
| |
Collapse
|
50
|
Abstract
PURPOSE OF REVIEW Identifying individuals at high fracture risk can be used to target those likely to derive the greatest benefit from treatment. This narrative review examines recent developments in using specific risk factors used to assess fracture risk, with a focus on publications in the last 3 years. RECENT FINDINGS There is expanding evidence for the recognition of individual clinical risk factors and clinical use of composite scores in the general population. Unfortunately, enthusiasm is dampened by three pragmatic randomized trials that raise questions about the effectiveness of widespread population screening using clinical fracture prediction tools given suboptimal participation and adherence. There have been refinements in risk assessment in special populations: men, patients with diabetes, and secondary causes of osteoporosis. New evidence supports the value of vertebral fracture assessment (VFA), high resolution peripheral quantitative CT (HR-pQCT), opportunistic screening using CT, skeletal strength assessment with finite element analysis (FEA), and trabecular bone score (TBS). The last 3 years have seen important developments in the area of fracture risk assessment, both in the research setting and translation to clinical practice. The next challenge will be incorporating these advances into routine work flows that can improve the identification of high risk individuals at the population level and meaningfully impact the ongoing crisis in osteoporosis management.
Collapse
Affiliation(s)
- William D Leslie
- Departments of Medicine and Radiology, University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | - Suzanne N Morin
- Department of Medicine, McGill University- McGill University Health Center, Montreal, Quebec, Canada
| |
Collapse
|