Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region

Multi-agent norm perception and induction in distributed healthcare

This paper presents a Multi-Agent Norm Perception and Induction Learning Model aimed at facilitating the integration of autonomous agent systems into distributed healthcare environments through dynamic interaction processes. The nature of the medical norm system and its sharing channels necessitates distinct approaches for Multi-Agent Systems to learn two types of norms. Building on this foundation, the model enables agents to simultaneously learn descriptive norms, which capture collective tendencies, and prescriptive norms, which dictate ideal behaviors. Through parameterized mixed probability density models and practice-enhanced Markov games, the multi-agent system perceives descriptive norms in dynamic interactions and captures emergent prescriptive norms. We conducted experiments using a dataset from a neurological medical center spanning from 2016 to 2020. The descriptive norm-sharing experiment results demonstrate that the model can effectively perceive the descriptive collective medical norms - which embody the current best clinical practices - across medical communities of varying scales. By contrasting this with the fact that the real descriptive diagnostic practice patterns in the neurological medical center dataset gradually converged over a period of 5 years, we find that the model, through prolonged learning and sharing processes, progressively mirrors the actual descriptive diagnostic trends and collective behavioral tendencies present within the medical community. In the experiment where multiple agents infer prescriptive norms within a dynamic healthcare environment, the agents effectively learned the key clinical protocols within the norm space H, which includes control norms, without developing high belief in invalid norms. Furthermore, the agents' belief update process was relatively smooth, avoiding any discontinuous stepwise updates.

Impact of health beliefs and risk perception on willingness to undergo osteoporosis assessment among perimenopausal and menopausal women in primary care: a descriptive cross-sectional study

BACKGROUND

Osteoporosis holds significant clinical importance as a major risk factor for fractures and the associated consequences of chronic pain, disability, loss of independence, decreased quality of life, and increased mortality. Studies have found varied levels of knowledge, risk perception and health beliefs about osteoporosis. The impact of health beliefs and risk perception on willingness to undergo osteoporosis assessment was not known. This study thus aimed to determine the factors that impact the willingness of peri-menopausal and menopausal women to undergo Bone Mineral Densitometry for osteoporosis assessment.

METHODS

The study was a descriptive cross-sectional study utilising self-administered questionnaires. Women aged 50 years and above were recruited via convenience sampling from a cluster of public primary care clinics in Singapore. The Osteoporosis Health Belief Scale (OHBS) was modified with permission for local context with good validity and reliability. The modified OHBS had 19 items in five subscales: perceived susceptibility to osteoporosis (risk perception), benefits and barriers to calcium intake, and benefits and barriers to exercise. Logistic regression was used to determine the predictors that impacted willingness to undergo osteoporosis assessment.

RESULTS

Of 342 women who participated in the study, the mean age was 62.29 years, most were Chinese (75.3%), married (85.3%) and had secondary education (53.4%). Only 15.2% had a family history of osteoporosis and 10.9% were classified as high risk for osteoporosis. Two-thirds of participants (66.1%) were willing to undergo osteoporosis assessment. Logistic regression found that women of Chinese ethnicity, older age, history of fractures and those with higher risk perception and exercise benefits scores were more likely to be willing to undergo osteoporosis assessment.

CONCLUSION

The study highlighted pertinent sociodemographic and clinical factors as well as risk perception and health beliefs that impacted willingness to undergo osteoporosis assessment. Knowledge of these factors will be useful when developing interventions to improve preventive behaviours for osteoporosis and increase uptake of osteoporosis assessment for those at risk.

Performance of the Osteoporosis Self-Assessment Tool for Asians (OSTA) Index for Osteoporosis Screening in Thai Men: A Cross-Sectional Study

Background Addressing the under-recognition of osteoporosis in men necessitates the use of suitable screening tools tailored to the male population. The Osteoporosis Self-Assessment Tool for Asians (OSTA) index is a reliable tool for evaluating the risk of osteoporosis. This cross-sectional study aims to assess the predictive performance of the OSTA index in Thai men. Additionally, the study compares the performance of the OSTA index with the Khon Kaen Osteoporosis Study (KKOS) score and an age cutoff value of ≥70 years. Methods Between November 2017 and October 2024, men aged 50 years or older who underwent dual-energy X-ray absorptiometry and did not receive any osteoporosis treatment were included. The performance of the individual OSTA index cutoff values in predicting osteoporosis was assessed. Results A total of 427 men were included in this study and classified into normal bone mineral density (BMD) (175 men, 41%), osteopenia (210 men, 49.2%), and osteoporosis (42 men, 9.8%). The mean age, weight, and body mass index were 76.4 years, 65.9 kg, and 24.1 kg/m², respectively. The OSTA index cutoff of -1 at any BMD site produced a Youden index of 0.187, with a sensitivity of 85.7% and a specificity of 33%. Meanwhile, the OSTA index cutoff of -4 at any BMD site resulted in a Youden index of 0.395, with a sensitivity of 59.5% and a specificity of 80%. The area under the receiver operating characteristic curve (AUC) of the KKOS score ≤-1 was 0.636. The AUC of the OSTA index ≤-1 was 0.594, which was significantly lower than the AUC of the KKOS score ≤-1 (P = 0.003). The AUC of age ≥70 years was 0.494, which was significantly lower than the AUC of the OSTA index ≤-1 (P < 0.001). Conclusion For osteoporosis screening in Thai men, the OSTA index cutoff value of -1 is more appropriate than a cutoff value of -4. However, the KKOS score cutoff value of ≤-1 serves as the most effective predictor for osteoporosis screening.

An insight for Fracture Liaison Service implementation: a qualitative study from a developing country

INTRODUCTION /OBJECTIVE

Osteoporosis often goes undetected until the first fracture, significantly increasing the risk of subsequent fractures. The Fracture Liaison Service (FLS) model aims to prevent secondary fractures and improve osteoporosis management. This study aims to provide a comprehensive overview of the current status of FLS implementation in Iran, applying the essential elements outlined in the FLS framework.

METHOD

This qualitative study used framework analysis to explore key components of the FLS framework from the perspectives of Iranian experts. Semi-structured, in-depth interviews were conducted over a 3-month period. Collaborative scenario synthesis was employed to accurately reflect the complexities of FLS operations.

RESULTS

A total of 13 participants with an average practical experience of 3.2 years contributed to the study. The results covered the people involved, needed information, locations, timeframes, and operational details of FLS stages, as well as quality improvement. The study confirmed the FLS framework's applicability in describing an implemented FLS and highlighted areas for improvement, such as coordinator training, role clarification, and data management issues.

CONCLUSION

Given the scarcity of comprehensive studies on FLS within Iran's context and the recent growth and expansion of FLS initiatives in the country, this study offers insights into FLS implementation from the perspective of experts, serving as a guiding resource for future initiatives in this domain. Future research may benefit from developing tailored questionnaires based on the FLS framework to gather insights from a larger population for a better assessment. Key points • Iran lacks specialized training programs for FLS coordinators. Developing these programs is crucial, particularly for healthcare professionals from non-nursing specialties. • There is a lack of clarity regarding the timeline for each stage of the FLS process. A context-specific timeline is needed to optimize service implementation and workflow. • There are inaccuracies in coding patient information that pose significant challenges, potentially undermining hospital statistics and the quality of FLS data.

Sequential therapy following teriparatide treatment in patients at high risk of osteoporotic patients

The use of medications in sequence is recommended in several osteoporosis guidelines to afford the best protection for the patient at very high risk of fracture. Sequential therapy following once-weekly as well as daily teriparatide treatment is a potent option for those patients.

Simple clinical predictors for making directive decisions in osteoporosis screening for women: a cross-sectional study

BACKGROUND

Osteoporosis screening strategies vary according to a country's policies. Simple and highly accurate diagnostic predictors should be developed and utilized. This cross-sectional study aimed to determine the diagnostic performances of weight, body mass index (BMI), and age for osteoporosis. Moreover, this study proposes and validates new cutoff values for these indicators.

METHODS

Women aged 50 years or older who underwent Dual-energy x-ray absorptiometry (DXA) and did not receive any treatment for osteoporosis were enrolled. Age, weight, and BMI were used to analyze the diagnostic models. New cutoff values were proposed using the maximum Youden index value.

RESULTS

A total of 1598 women were classified into normal bone mineral density, osteopenia, and osteoporosis groups. The mean age, weight, and BMI were 73.2 years, 53.6 kg, and 23.2 kg/m2, respectively, in the osteoporosis group, which significantly differed from those of the other groups. The new cutoff values for diagnosing osteoporosis at any site were 57.4 kg for weight, 23.8 kg/m2 for BMI, and 72 years for age. The area under the receiver operating characteristic curve (AUC) for weight < 57.4 kg, BMI < 23.8 kg/m2, and age ≥ 72 years cutoff values were 0.664, 0.633, and 0.558, respectively. The weight cutoff value yielded a significantly higher AUC than the BMI and age cutoff values (P = 0.002 and P < 0.001, respectively).

CONCLUSIONS

This study proposes new cutoff values for simple clinical predictors to facilitate directive decision-making in osteoporosis screening in women. Weight, which are easily obtained in clinical practice, are the most effective predictors of osteoporosis screening.

Automated Screening of Hip X-rays for Osteoporosis by Singh's Index Using Machine Learning Algorithms

INTRODUCTION

Osteoporosis is a significant and growing global public health problem, projected to increase in the next decade. The Singh Index (SI) is a simple, semi-quantitative evaluation tool for diagnosing osteoporosis with plain hip radiographs based on the visibility of the trabecular pattern in the proximal femur. This work aims to develop an automated tool to diagnose osteoporosis using SI of hip radiograph images with the help of machine learning algorithms.

METHODS

We used 830 hip X-ray images collected from Indian men and women aged between 20 and 70 which were annotated and labeled for appropriate SI. We employed three state-of-the-art machine learning algorithms-Vision Transformer (ViT), MobileNet-V3, and a Stacked Convolutional Neural Network (CNN)-for image pre-processing, feature extraction, and automation. Each algorithm was evaluated and compared for accuracy, precision, recall, and generalization capabilities to diagnose osteoporosis.

RESULTS

The ViT model achieved an overall accuracy of 62.6% with macro-averages of 0.672, 0.597, and 0.622 for precision, recall, and F1 score, respectively. MobileNet-V3 presented a more encouraging accuracy of 69.6% with macro-averages for precision, recall, and F1 score of 0.845, 0.636, and 0.652, respectively. The stacked CNN model demonstrated the strongest performance, achieving an accuracy of 93.6% with well-balanced precision, recall, and F1-score metrics.

CONCLUSION

The superior accuracy, precision-recall balance, and high F1-scores of the stacked CNN model make it the most reliable tool for screening radiographs and diagnosing osteoporosis using the SI.

Developing fracture liaison service framework based on comparative analysis and scoping review

This research conducts a comparative analysis and scoping review of 105 studies in the field of Fracture Liaison Service (FLS). The resulting two-dimensional framework represents a significant step toward FLS implementation.

PURPOSE

The primary goal is to review interventions in real world settings in order to provide the FLS framework that specifies the essential elements of its implementation and offers different perspectives on that.

METHOD

This study encompasses two phases: a comparative analysis of existing FLS models, including "Capture the Fracture," "5IQ," and "Ganda," and a scoping review from 2012 to 2022 in PubMed, Web of Science, Scopus, ProQuest, and IEEE databases limited to publications in English.

RESULTS

The resulting model of comparative analysis identifies patient identification, investigation, intervention and integration or continuity of care as the four main stages of FLS. Additionally, the elements of quality and information span across all stages. Following comparative analysis, the framework is designed to be used for content analysis of the included studies in the scoping review. The intersection of columns (Who, Where, When, What, How, Quality) with rows (Identification, Investigation, Intervention, and continuity of care) yields a set of questions, answered in tabular form based on the scoping review.

CONCLUSION

The framework offers potential benefits in facilitating the adoption of effective approaches for FLS implementation. It is recommended to undertake an in-depth review of each of these components in order to uncover novel and innovative approaches for improving their implementation.

Secondary fracture prevention in primary care: a narrative review

The global burden of osteoporosis continues to rise with an ageing population. Untreated osteoporotic fractures not only heighten the risk of subsequent fractures but are associated with excess mortality. Although primary care guidelines consistently stress the importance of secondary fracture prevention, fewer than 20% of patients are appropriately treated for osteoporosis following an initial osteoporotic fracture. This worldwide phenomenon is known as the osteoporosis care gap. This literature review examines the barriers to secondary fracture prevention in primary care and evaluates the effectiveness of targeted primary care interventions. Common themes emerged from the majority of qualitative studies, including a need for improved communication between the hospital team and primary care, better defined responsibilities and osteoporosis-directed education for the primary care physicians. Quantitative studies demonstrated that most targeted, intensive interventions aimed at educating patients and their primary care physician about osteoporosis treatment significantly increased rates of investigation and treatment. Greater uptake of models of secondary fracture prevention in primary care is urgently needed to address the osteoporosis care gap.

Evaluating compliance with the care standard of proactively assessing bone health in patients with diabetes: a pilot audit of practice across Asia by the Asia Pacific Consortium on Osteoporosis (APCO)

This pilot audit explored how bone health is assessed patients with diabetes in diverse centres across Asia. Only 343 of 1092 (31%) audited patients had a bone health assessment, 27% of whom were diagnosed with osteoporosis. Quality improvement strategies are needed to address gaps in patient care in this area.

PURPOSE

The Asia Pacific Consortium on Osteoporosis (APCO) Framework outlines clinical standards for assessing and managing osteoporosis. A pilot audit evaluated adherence to clinical standard 4, which states that bone health should be assessed in patients with conditions associated with bone loss and/or increased fracture risk; this report summarises the audit findings in patients with diabetes. A secondary aim was to assess the practicality and real-world use of the APCO bone health audit tool kit.

METHODS

Eight centres across Asia participated in the pilot audit, selecting diabetes as the target group. Participants reviewed their practice records for at least 20 consecutively treated patients with the target condition. Questions covered routine investigations, bone health assessment, osteoporosis diagnosis, and patient referral pathways. Data were summarised descriptively.

RESULTS

The participants represented public hospitals, university medical centres, and private clinics from India, Malaysia, Pakistan, Singapore, Taiwan, and Vietnam that see an estimated total of 95,000 patients with diabetes per year. Overall, only 343 of 1092 audited patients (31%) had a bone health assessment. Osteoporosis was subsequently diagnosed in 92 of 343 (27%) patients.

CONCLUSION

Bone health was not assessed in most patients with diabetes. The results provide insight into current practices across diverse Asian centres and demonstrate the practical value of the audit tool kit. Participant feedback has been used to improve the tool kit. Results of this pilot audit are being used in the respective centres to inform quality improvement projects needed to overcome the gap in patient care.

Comparison between Two Different Synthesis Methods of Strontium-Doped Hydroxyapatite Designed for Osteoporotic Bone Restoration

Development of efficient controlled local release of drugs that prevent systemic side effects is a challenge for anti-osteoporotic treatments. Research for new bone-regeneration materials is of high importance. Strontium (Sr) is known as an anti-resorptive and anabolic agent useful in treating osteoporosis. In this study, we compared two different types of synthesis used for obtaining nano hydroxyapatite (HA) and Sr-containing nano hydroxyapatite (SrHA) for bone tissue engineering. Synthesis of HA and SrHA was performed using co-precipitation and hydrothermal methods. Regardless of the synthesis route for the SrHA, the intended content of Sr was 1, 5, 10, 20, and 30 molar %. The chemical, morphological, and biocompatibility properties of HA and SrHA were investigated. Based on our results, it was shown that HA and SrHA exhibited low cytotoxicity and demonstrated toxic behavior only at higher Sr concentrations.

Establishment and validation of a nomogram clinical prediction model for osteoporosis in senile patients with type 2 diabetes mellitus

This study aimed to develop a predictive nomogram model to estimate the odds of osteoporosis (OP) in elderly patients with type 2 diabetes mellitus (T2DM) and validate its prediction efficiency. The hospitalized elderly patients with T2DM from the Affiliated Hospital of North Sichuan Medical University between July 2022 and March 2023 were included in this study. We sorted them into the model group and the validation group with a ratio of 7:3 randomly. The selection operator regression (LASSO) algorithm was utilized to select the optimal matching factors, which were then included in a multifactorial forward stepwise logistic regression to determine independent influencing factors and develop a nomogram. The discrimination, accuracy, and clinical efficacy of the nomogram model were analyzed utilizing the receiver operating characteristic (ROC) curve, calibration curve, and clinical decision curve analysis (DCA). A total of 379 study participants were included in this study. Gender (OR = 8.801, 95% CI 4.695-16.499), Geriatric Nutritional Risk Index (GNRI) < 98 (OR = 4.698, 95% CI 2.416-9.135), serum calcium (Ca) (OR = 0.023, 95% CI 0.003-0.154), glycated hemoglobin (HbA1c) (OR = 1.181, 95% CI 1.055-1.322), duration of diabetes (OR = 1.076, 95% CI 1.034-1.119), and serum creatinine (SCr) (OR = 0.984, 95% CI 0.975-0.993) were identified as independent influencing factors for DOP occurrence in the elderly. The area under the curve (AUC) of the nomogram model was 0.844 (95% CI 0.797-0.89) in the modeling group and 0.878 (95% CI 0.814-0.942) in the validation group. The nomogram clinical prediction model was well generalized and had moderate predictive value (AUC > 0.7), better calibration, and better clinical benefit. The nomogram model established in this study has good discrimination and accuracy, allowing for intuitive and individualized analysis of the risk of DOP occurrence in elderly individuals. It can identify high-risk populations and facilitate the development of effective preventive measures.

Impact of the COVID-19 Pandemic on Adherence to Denosumab Therapy: A Single Center Study

STUDY DESIGN

A retrospective comparative study of denosumab therapy adherence before and during the coronavirus disease 2019 (COVID-19) pandemic.

PURPOSE

To evaluate the effect of the COVID-19 pandemic on denosumab therapy adherence in Japan.

OVERVIEW OF LITERATURE

Denosumab is a monoclonal antibody for osteoporosis treatment. Delayed denosumab injections are associated with reduced treatment responses, which was a concern during the COVID-19 pandemic.

METHODS

Participants included 376 patients who received denosumab (60 mg every 6 months) from January 2013 to June 2021. The time from therapy initiation to discontinuation was used to measure persistence, and that between initial and subsequent injections was used to determine adherence. The pandemic period was from March 2020 to December 2021.

RESULTS

Patients were divided into those treated after March 2020 (pandemic group, n=244) and those who discontinued treatment before March 2020 (non-pandemic group, n=132). Non-persistent cases accounted for 154, including 24 (20%), 64 (19%), and 66 (53%) aged ≤59 years, 60-79 years, and ≥80 years, respectively. The overall persistence rate at 78 months was 59.2%. Postponed cases were significantly lower in the non-pandemic group than in the pandemic group (8% vs. 15%, p =0.042). Postponement with a delay of 1-2 months did not significantly differ between the two groups, but with a significant difference for a delay of ≥3 months (0% vs. 36%, p =0.024).

CONCLUSIONS

Denosumab adherence remained constant but postponed cases significantly increased during the COVID-19 pandemic. Better communication by health providers on denosumab adherence and alternative administration may reduce dosing interruptions in similar pandemic situations.

Using sequential pharmacotherapy for the treatment of osteoporosis: an update of the literature

INTRODUCTION

Osteoporosis, which is characterized by compromised bone density and heightened susceptibility to fractures, is a substantial public health concern, especially among the aging population. Underdiagnosis, undertreatment, and therapy non-adherence contribute to its impact. Anabolic and dual-action agents like teriparatide, abaloparatide, and romosozumab have emerged as effective treatments, allowing rapid gains in bone mineral density (BMD) and reducing fracture risk. However, administering treatments in the correct order is paramount, with an 'anabolic first' approach gaining traction for patients at high risk of fractures. This strategy involves starting anabolic therapies, followed by antiresorptive agents as maintenance therapy. It is important to note that the effectiveness of anabolic agents differs between treatment-naive and previously treated patients: tailored treatment approaches are therefore necessary. This comprehensive strategy adheres to clinical guidelines, emphasizing individualized care, early intervention, and patient-centered management to mitigate the burden of osteoporosis and enhance patients' quality of life.

AREA COVERED

The aim of this review is to summarize recent evidence on the sequential treatment of osteoporosis and to provide recommendations on the best treatment strategies.

EXPERT OPINION

Effective treatments, such as anabolic agents, are key in high-risk patients, who require an 'anabolic first' approach. Sequential therapy, specifically tailored to a patient's history, can help to optimize prevention and management of fractures.

A summary of the Malaysian Clinical Practice Guidelines on the management of postmenopausal osteoporosis, 2022

Objectives

The aim of these Clinical Practice Guidelines is to provide evidence-based recommendations to assist healthcare providers in the screening, diagnosis and management of patients with postmenopausal osteoporosis (OP).

Methods

A list of key clinical questions on the assessment, diagnosis and treatment of OP was formulated. A literature search using the PubMed, Medline, Cochrane Databases of Systematic Reviews, and OVID electronic databases identified all relevant articles on OP based on the key clinical questions, from 2014 onwards, to update from the 2015 edition. The articles were graded using the SIGN50 format. For each statement, studies with the highest level of evidence were used to frame the recommendation.

Results

This article summarizes the diagnostic and treatment pathways for postmenopausal OP. Risk stratification of patients with OP encompasses clinical risk factors, bone mineral density measurements and FRAX risk estimates. Non-pharmacological measures including adequate calcium and vitamin D, regular exercise and falls prevention are recommended. Pharmacological measures depend on patients' fracture risk status. Very high-risk individuals are recommended for treatment with an anabolic agent, if available, followed by an anti-resorptive agent. Alternatively, parenteral anti-resorptive agents can be used. High-risk individuals should be treated with anti-resorptive agents. In low-risk individuals, menopausal hormone replacement or selective estrogen receptor modulators can be used, if indicated. Patients should be assessed regularly to monitor treatment response and treatment adjusted, as appropriate.

Conclusions

The pathways for the management of postmenopausal OP in Malaysia have been updated. Incorporation of fracture risk stratification can guide appropriate treatment.

GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management-a Pakistani context

Due to its high prevalence, we aimed to create postmenopausal osteoporosis clinical practice guideline via GRADE-ADOLOPMENT for Pakistan. We recommend a higher dose (2000-4000 IU) of vitamin D for osteoporotic patients who are old, have malabsorption, or are obese. The guideline will help standardize care provision and improve health care outcomes for osteoporosis.

PURPOSE

Postmenopausal osteoporosis affects one in every five postmenopausal women in Pakistan. An evidence-based clinical practice guideline (CPG) is needed to standardize care provision to optimize health outcomes. Hence, we aimed to develop CPG for the management of postmenopausal osteoporosis in Pakistan.

METHODS

The GRADE-ADOLOPMENT process was used to adopt (as is or with minor changes), exclude (omit), or adapt (modify based on local context) recommendations to the source guideline (SG)-clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update from American Association of Clinical Endocrinology (AACE).

RESULTS

The SG was "adoloped" to cater to the local context. The SG consisted of 51 recommendations. Forty-five recommendations were adopted as is. Due to unavailability of drugs, 4 recommendations were adopted with minor changes, and one was excluded, while one recommendation was adopted with the inclusion of use of a surrogate FRAX tool specific for Pakistan. One recommendation regarding vitamin D dosage was adapted to recommend a dose of 2000-4000 IU of vitamin D in patients with obesity, malabsorption, and old age.

CONCLUSION

The developed Pakistani postmenopausal osteoporosis guideline consists of 50 recommendations. The guideline created recommends a higher dose (2000-4000 IU) of vitamin D for patients who are old, have malabsorption, or are obese, which is an adaptation from the SG by the AACE. This higher dose is justified as lower doses prove to be suboptimal in these groups and should be complemented with baseline vitamin D and calcium levels.

Exercise to Prevent and Manage Frailty and Fragility Fractures

PURPOSE OF REVIEW

This review identifies exercise-based recommendations to prevent and manage frailty and fragility fractures from current clinical practice guidelines. We also critically assess recently published literature in relation to exercise interventions to mitigate frailty and fragility fractures.

RECENT FINDINGS

Most guidelines presented similar recommendations that included the prescription of individually tailored, multicomponent exercise programs, discouragement of prolonged sitting and inactivity, and combining exercise with optimal nutrition. To target frailty, guidelines recommend supervised progressive resistance training (PRT). For osteoporosis and fragility fractures, exercise should include weight-bearing impact activities and PRT to target bone mineral density (BMD) at the hip and spine, and also incorporate balance and mobility training, posture exercises, and functional exercise relevant to activities of daily living to reduce falls risk. Walking as a singular intervention has limited benefits for frailty and fragility fracture prevention and management. Current evidence-based clinical practice guidelines for frailty, osteoporosis, and fracture prevention recommend a multifaceted and targeted approach to optimise muscle mass, strength, power, and functional mobility as well as BMD.

Nurse-Initiated Fall and Osteoporosis Screening for Older Adults in the Emergency Department

Background Many older adults presenting to the emergency department (ED) after a fall are discharged without adequate assessment of their fall risk. A nurse-initiated protocol was introduced for the early screening of older adults with injurious falls. We aimed to promote osteoporosis education and right-site them to appropriate outpatient resources in the community. Methodology In this study, we included ≥65-year-old adults who attended the ED with injurious falls or near falls between December 2019 and December 2020. An ED nurse trained in basic geriatric care performed the cognitive assessment and provided advice on diet, footwear, fall safety, calcium/vitamin D supplementation, and osteoporosis screening. Results A total of 70 (75.7% female) patients aged 65-93 years were included. In total, 34 (48.6%) were started on calcium/vitamin D supplements and 22 (31.4%) went on to receive outpatient bone mineral density scans. Only three patients reattended the ED for recurrent falls/fractures in the six-month follow-up period. Conclusions A nurse-initiated fall and osteoporosis screening protocol is a feasible model of care for targeted screening and education of older adults who present to the ED with injurious falls.

A nomogram for predicting residual low back pain after percutaneous kyphoplasty in osteoporotic vertebral compression fractures

To establish a risk prediction model for residual low back pain after percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures. We used retrospective data for model construction and evaluated the model using internal validation and temporal external validation and finally concluded that the model had good predictive performance.

INTRODUCTION

The cause of residual low back pain in patients with osteoporotic vertebral compression fractures (OVCFs) after PKP remains highly controversial, and our goal was to investigate the most likely cause and to develop a novel nomogram for the prediction of residual low back pain and to evaluate the predictive performance of the model.

METHODS

The clinical data of 281 patients with OVCFs who underwent PKP at our hospital from July 2019 to July 2020 were reviewed. The optimal logistic regression model was determined by lasso regression for multivariate analysis, thus constructing a nomogram. Bootstrap was used to perfomance the internal validation; receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to assess the predictive performance and clinical utility of the model, respectively. Temporal external validation of the model was also performed using retrospective data from 126 patients who underwent PKP at our hospital from January 2021 to October 2021.

RESULTS

Lasso regression cross-validation showed that the variables with non-zero coefficients were the number of surgical vertebrae, preoperative bone mineral density (pre-BMD), smoking history, thoracolumbar fascia injury (TLFI), intraoperative facet joint injury (FJI), and postoperative incomplete cementing of the fracture line (ICFL). The above factors were included in the multivariate analysis and showed that the pre-BMD, smoking history, TLFI, FJI, and ICFL were independent risk factors for residual low back pain (P < 0.05). The ROC and calibration curve of the original model and temporal external validation indicated a good predictive power of the model. The DCA curve suggested that the model has good clinical practicability.

CONCLUSION

The risk prediction model has good predictive performance and clinical practicability, which can provide a certain basis for clinical decision-making in patients with OVCFs.

Prevalence of osteoporosis and incidence of related fractures in developed economies in the Asia Pacific region: a systematic review

Robust data on osteoporosis in the Asia Pacific region could improve healthcare decision-making. Osteoporosis affects 10-30% of women aged 40 + , and up to 10% of men in 7 developed economies in Asia Pacific. Fractures affect 500-1000 adults aged 50 + per 100,000 person-years. Policymakers and clinicians must address this problem.

PURPOSE

Osteoporosis and associated fractures result in considerable morbidity, loss of productivity, early mortality, and increased healthcare expenses. Many countries in the Asia Pacific (AP) region, especially middle- and higher-income economies, are faced with aging and increasingly sedentary populations. It is critical to consolidate and analyze the available information on the prevalence and incidence of the disease in these countries.

METHODS

We systematically reviewed articles and gray literature for Australia, China, Hong Kong, Japan, Singapore, South Korea, and Taiwan. We searched PubMed, ScienceDirect, JSTOR, Cochrane, Google Scholar, and other databases for data published 2009-2018. We included articles with prevalence or incidence estimates for adults with osteoporosis or related fractures.

RESULTS

All locations had data available, but of widely varying quantity and quality. Most estimates for osteoporosis prevalence ranged from 10 to 30% for women ages 40 and older, and up to 10% for men. Osteoporotic fracture incidence typically ranged between 500 and 1000 per 100,000 person-years among adults aged 50 and older. Both outcomes typically increased with age and were more common among women.

CONCLUSION

Osteoporosis and associated fractures affect significant portions of the adult population in developed economies in the AP region. Governments and healthcare systems must consider how best to prevent and diagnose osteoporosis, and manage affected individuals, to reduce healthcare costs and mortality associated with fractures.

Feasibility of assessing male osteoporosis using MRI IDEAL-IQ sequence of proximal femur in prostate cancer patients

Osteoporosis is often accompanied by bone loss with fat accumulation of the red marrow. A novel technique for quantification of iron and fat content by MRI IDEAL-IQ can visualize hematopoietic areas and fatty deposits in bone marrow; however, the relationship between these indices and total hip bone mineral density (BMD) remains unclear. In this study, the proximal femur of 104 men who underwent pelvic MRI and bone densitometry prior to treatment for non-metastatic prostate cancer was retrospectively examined to investigate the R2* value to quantify iron and proton density fat fraction (PDFF) to assess bone marrow fat content. R2* was significantly positively correlated with BMD (r = 0.6017, p < 0.0001), and PDFF was not correlated with BMD (r = -0.1302, p = 0.0512). Patients with BMD T-score ≤ -2.5 had significantly lower R2* than patients with BMD T-score > -2.5; however, there was no significant difference in PDFF. In the ROC analysis, which examined the predictive ability of R2* with BMD T-score ≤ -2.5 as an outcome, the cut-off value of R2* was 50.7 s^-1 (AUC 0.817). These results show R2* correlated with BMD. R2* may be a non-invasive surrogate marker for diagnosing male osteoporosis.

The why and how of sequential and combination therapy in osteoporosis. A review of the current evidence

It is now well recognized that over the lifetime of a patient with osteoporosis, more than one medication will be needed to treat the disease and to decrease fracture risk. Though current gaps in osteoporosis therapy can be potentially mitigated with sequential and combination regimens, how to move seamlessly amongst the multiple treatments currently available for osteoporosis for sustained efficacy is still unclear. Data from recent studies show that an anabolic agent such as teriparatide or romosozumab followed by an antiresorptive affords maximal gain in BMD and possibly better and earlier fracture risk reduction compared to a regimen which follows the opposite sequence. Sequentially moving to a bisphosphonate such as alendronate from an anabolic agent such as abaloparatide has also been shown to preserve the fracture reduction benefits seen with the latter. This sequence of an anabolic agent followed by an antiresorptive should especially be considered in the high-risk patient with imminent fracture risk to rapidly reduce the risk of subsequent fractures. The data surrounding optimum timing of initiation of bisphosphonate therapy following denosumab discontinuation is still unclear. Though data suggests that combining a bisphosphonate with teriparatide does not provide substantial BMD gains compared to monotherapy, the concomitant administration of denosumab with teriparatide has been shown to significantly increase areal BMD as well as to increase volumetric BMD and estimated bone strength. This narrative review explores the available evidence regarding the various sequential and combination therapy approaches and the potential role they could play in better managing osteoporosis.

The global burden of fragility fractures - what are the differences, and where are the gaps

The current burden of fragility fractures is enormous, and it is set to increase rapidly in the coming decades as humankind enters a new demographic era. The purpose of this review is to consider, in different settings: • The human and economic toll of fragility fractures. • Risk factors for fragility fractures. • Current acute management of fragility fractures. • Current care gaps in both secondary and primary fracture prevention. A summary of global, regional, and national initiatives to improve the quality of care is provided, in addition to proposals for the research agenda. Systematic approaches to improve the acute care, rehabilitation and prevention of fragility fractures need to be developed and implemented rapidly and at scale in high-, middle- and low-income countries throughout the world. This must be an essential component of our response to the ageing of the global population during the remainder of the current United Nations - World Health Organization "Decade of Healthy Ageing".

Quality improvement initiatives in the care and prevention of fragility fractures in the Asia Pacific region

This narrative review summarises ongoing challenges and progress in the care and prevention of fragility fractures across the Asia Pacific region since mid-2019. The approaches taken could inform development of national bone health improvement Road Maps to be implemented at scale during the United Nations 'Decade of Healthy Ageing'.

PURPOSE

This narrative review summarises recent studies that characterise the burden of fragility fractures, current care gaps and quality improvement initiatives intended to improve the care and prevention of fragility fractures across the Asia Pacific region.

METHODS

The review focuses on published studies, reports and quality improvement initiatives undertaken during the period July 2019 to May 2022.

RESULTS

Epidemiological studies conducted in countries and regions throughout Asia Pacific highlight the current and projected increasing burden of fragility fractures. Recent studies and reports document a persistent and pervasive post-fracture care gap among people who have sustained fragility fractures. Global initiatives developed by the Fragility Fracture Network and International Osteoporosis Foundation have gained significant momentum in the Asia Pacific region, despite the disruption caused by the COVID-pandemic. The Asia Pacific Fragility Fracture Alliance has developed educational resources including a Hip Fracture Registry Toolbox and a Primary Care Physician Education Toolkit. The Asia Pacific Osteoporosis and Fragility Fractures Society-a new section of the Asia Pacific Orthopaedic Association-is working to engage orthopaedic surgeons across the region in the care and prevention of fragility fractures. The Asia Pacific Consortium on Osteoporosis developed a framework to support national clinical guidelines development groups. Considerable activity at the national level is evident in many countries across the region.

CONCLUSION

Development and implementation of national Road Maps informed by the findings of this review are urgently required to respond to the epidemiological emergency posed by fragility fractures during the United Nations 'Decade of Healthy Ageing'.

Experience of a systematic approach to care and prevention of fragility fractures in New Zealand

This narrative review describes efforts to improve the care and prevention of fragility fractures in New Zealand from 2012 to 2022. This includes development of clinical standards and registries to benchmark provision of care, and public awareness campaigns to promote a life-course approach to bone health.

PURPOSE

This review describes the development and implementation of a systematic approach to care and prevention for New Zealanders with fragility fractures, and those at high risk of first fracture. Progression of existing initiatives and introduction of new initiatives are proposed for the period 2022 to 2030.

METHODS

In 2012, Osteoporosis New Zealand developed and published a strategy with objectives relating to people who sustain hip and other fragility fractures, those at high risk of first fragility fracture or falls and all older people. The strategy also advocated formation of a national fragility fracture alliance to expedite change.

RESULTS

In 2017, a previously informal national alliance was formalised under the Live Stronger for Longer programme, which includes stakeholder organisations from relevant sectors, including government, healthcare professionals, charities and the health system. Outputs of this alliance include development of Australian and New Zealand clinical guidelines, clinical standards and quality indicators and a bi-national registry that underpins efforts to improve hip fracture care. All 22 hospitals in New Zealand that operate on hip fracture patients currently submit data to the registry. An analogous approach is ongoing to improve secondary fracture prevention for people who sustain fragility fractures at other sites through nationwide access to Fracture Liaison Services.

CONCLUSION

Widespread participation in national registries is enabling benchmarking against clinical standards as a means to improve the care of hip and other fragility fractures in New Zealand. An ongoing quality improvement programme is focused on eliminating unwarranted variation in delivery of secondary fracture prevention.

Recent Information on Vitamin D Deficiency in an Adult Korean Population Visiting Local Clinics and Hospitals

We retrospectively reviewed serum 25-hydroxy vitamin D (25(OH)D) test results from an adult Korean population visiting local clinics and hospitals between July 2017 and December 2021 to gather recent information on the prevalence of vitamin D deficiency. The prevalence of vitamin D deficiency status was investigated according to criteria offered by various clinical guidelines. During the study period, 180,289 subjects (29,658 men and 150,631 women) were tested for 25(OH)D. The overall prevalence rates of vitamin D deficiency status based on 25(OH)D level were as follows: 0.4% for <5 ng/mL, 12.5% for <10 ng/mL, 20.6% for <12 ng/mL, 49.4% for <20 ng/mL, and <75.3% for <30 ng/mL. Women tested their 25(OH)D level more frequently than men, and the overall prevalence of 25(OH)D < 10 ng/mL was higher among women than men, while that of 25(OH)D <30 ng/mL was lower among women than men. Among age groups, the prevalence of 25(OH)D <30 ng/mL was higher in younger patients (20s−40s, 79.6−85.5%) than older ones (≥50 years, 62.6−69.2%). The overall prevalence of vitamin D deficiency decreased over time from 2018 to 2021. Future studies are needed to clarify the clinical impact of this change.

Harmonization of Osteoporosis Guidelines: Paving the Way for Disrupting the Status Quo in Osteoporosis Management in the Asia Pacific

In the Asia Pacific (AP) region, osteoporosis and its consequence of fragility fractures are not widely recognized as a major public health problem. Several challenges including underdiagnosis and undertreatment exist. The Asia Pacific Consortium on Osteoporosis (APCO) is a nonpartisan and apolitical organization comprising musculoskeletal experts and stakeholders from both private and public sectors who have united to develop tangible solutions for these substantive challenges. APCO's vision is to reduce the burden of osteoporosis and fragility fractures in the AP region. Heterogeneity in both scope and recommendations among the available clinical practice guidelines (CPGs) contribute to the large osteoporosis treatment gap in the Asia Pacific. APCO has therefore developed a pan Asia-Oceania harmonized set of standards of care (The Framework), for the screening, diagnosis, and management of osteoporosis. First, a structured analysis of the 18 extant AP CPGs was completed. Subsequently, a prioritization of themes and agreement on fundamental principles in osteoporosis management were made through a Delphi process of consensus building. This approach, ensuring the opinions of all participating members were equally considered, was especially useful for a geographically diverse group such as APCO. It is hoped that the Framework will serve as a platform upon which new AP national CPGs can be developed and existing ones be revised. APCO is currently embarking on country-specific engagement plans to embed the Framework in clinical practice in the AP region. This is through partnering with regulatory bodies and national guidelines development authorities, through peer-to-peer health care professional education and by conducting path finder audits to benchmark current osteoporosis services against the Framework standards. The principles underpinning the harmonization of guidelines in the AP region can also be utilized in other parts of the world that have similar socioeconomic diversity and heterogeneity of healthcare resources. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Adherence to dosing schedule of denosumab therapy for osteoporosis during COVID-19 lockdown: an electronic medical record and pharmacy claims database study from Asia

COVID-19 lockdowns have impacted management of chronic diseases such as osteoporosis. Adherence to the 6-monthly dosing schedule of denosumab, the parenteral anti-osteoporosis medication most often used in Singapore, was significantly reduced during the lockdown period compared to that during pre-COVID-19 times. Patients managed by endocrinologists were more likely to be adherent.

PURPOSE

No study thus far has quantified actual adherence rates to anti-osteoporosis therapy with denosumab during COVID-19 or explored factors associated with it. We aimed to estimate the adherence rates to denosumab in Singaporean men and women during COVID-19 lockdown and to compare it with those during the pre-COVID-19 period.

METHOD

We conducted this retrospective, electronic medical records, and pharmacy claims database study at Singapore General Hospital, the largest hospital in the country. Patients initiated on subcutaneous denosumab between August 2019 and December 2019 and were thus scheduled to receive the second dose during the COVID-19 first-wave period from February 2020 to June 2020 (lockdown group) were analyzed, as were patients initiated anytime on denosumab between September 2011 and December 2018 (pre-COVID-19 group). Data extracted from the hospital's electronic prescription platform and patients' pharmacy purchase records were matched. Adherence was defined as being punctual (with an allowable delay of up to 4 weeks) with the second dose scheduled 6 months from the 1st dose. A sensitivity analysis with an allowable delay up to 8 weeks was also performed. We compared the adherence rates between the two periods and explored factors associated with adherence.

RESULTS

A total of 768 and 1458 patients respectively during the lockdown and pre-COVID-19 periods were analyzed. The mean adherence rate during lockdown was 63.9%. The odds of being adherent during lockdown were higher if patients were managed by endocrinologists as opposed to those by other specialists [OR 2.516 (95% CI: 1.836-3.448); p < 0.001]. Adherence rates during the pre-COVID-19 period was 75.4%. Overall, the odds of being adherent to denosumab was significantly lower during lockdown than that during the pre-COVID-19 period [OR 0.525 (95% CI 0.430-0.640); p < 0.001], and odds of being adherent were higher if patients were managed by endocrinologists than if they were managed by other specialists (OR 1.765 (95% CI: 1.444-2.158; p < 0.001).

CONCLUSION

Adherence to denosumab was significantly lower during COVID-19 lockdown than the pre-COVID-19 period. The odds of being adherent were higher in patients managed by endocrinologists. Whether healthcare providers from certain specialties spend more time counselling and educating patients about the importance of adherence to osteoporosis medications needs to be explored further.

Bridging the gaps in secondary fracture prevention at a single center in Pakistan-compliance with the IOF best practice framework

PURPOSE

The International Osteoporosis Foundation (IOF) formulated a set of best practice framework as an international benchmark for secondary fracture prevention (SFP) and fracture liaison services (FLS), delineating essential elements of service delivery. The aim of this audit was to assess compliance with the IOF standards for patients ≥ 50 years presenting with fragility hip fractures at a tertiary care center in Pakistan.

METHODS

A retrospective sample of hip fracture cases from Jan 2019 to Dec 2019, treated at the section of Orthopedic Surgery, Aga Khan University, Karachi, was conducted. After excluding high energy trauma cases and patients younger than 50 years of age, medical records were audited, using a pre-structured Performa based on IOF standards. Compliance level of 0, 1, 2, and 3 was recorded as defined by IOF. Microsoft excel was used for data analysis.

RESULTS

A compliance level of 3 was recorded for patient identification and fall prevention services, whereas level 1 was attained for database maintenance for 25 (100%) cases. For medication initiation, level 0 was recorded for all the cases; however, 8 (32%) cases were prescribed calcium and vitamin D supplements. For the standards, including post-fracture assessment timing, evaluation of secondary causes of osteoporosis, multifaceted assessment, medication review, communication strategy, and long-term management, a level 0 was noted for 25 (100%) cases. Moreover, no recommended assessment guidelines were followed uniformly.

CONCLUSION

The care gaps identified require substantial efforts to ensure adequate implementation of the overall best practice standards for SFP, necessitating the need for FLS initiation and establishment of fracture care pathway.

Treatment indications and thresholds of intervention: consensus and controversies in osteoporosis

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.