Osteoporosis: burden, health care provision and opportunities in the EU: a report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA)

Causal impact of DNA methylation on refracture in elderly individuals with osteoporosis - a prospective cohort study

BACKGROUND

Osteoporotic vertebral compression fractures (OVCF) in the elderly increase refracture risk post-surgery, leading to higher mortality rates. Genome-wide association studies (GWAS) have identified susceptibility genes for osteoporosis, but the phenotypic variance explained by these genes has been limited, indicating the need to explore additional causal factors. Epigenetic modifications, such as DNA methylation, may influence osteoporosis and refracture risk. However, prospective cohorts for assessing epigenetic alterations in Chinese elderly patients are lacking. Here, we propose to conduct a prospective cohort study to investigate the causal network of DNA polymorphisms, DNA methylation, and environmental factors on the development of osteoporosis and the risk of refracture.

METHODS

We will collect vertebral and peripheral blood from 500 elderly OVCF patients undergoing surgery, extract DNA, and generate whole genome genotype data and DNA methylation data. Observation indicators will be collected and combined with one-year follow-up data. A healthy control group will be selected from a natural population cohort. Epigenome-wide association studies (EWAS) of osteoporosis and bone mineral density will be conducted. Differential methylation analysis will compare candidate gene methylation patterns in patients with and without refracture. Multi-omics prediction models using genetic variants and DNA methylation sites will be built to predict OVCF risk.

DISCUSSION

This study will be the first large-scale population-based study of osteoporosis and bone mineral density phenotypes based on genome-wide data, multi-time point methylation data, and phenotype data. By analyzing methylation changes related to osteoporosis and bone mineral density in OVCF patients, the study will explore the feasibility of DNA methylation in evaluating postoperative osteoporosis intervention effects. The findings may identify new molecular markers for effective anti-osteoporosis treatment and inform individualized prevention and treatment strategies.

TRIAL REGISTRATION

chictr.org.cn ChiCTR2200065316, 02/11/2022.

Discretizing low-intensity whole-body vibration into bouts with short rest intervals promotes bone defect repair in osteoporotic mice

Continuous administration of low-intensity whole-body vibration (WBV) gradually diminishes bone mechanosensitivity over time, leading to a weakening of its osteogenic effect. We investigated whether discretizing WBV into bouts with short rest intervals was effective in enhancing osteoporotic bone repair. Ten-week-old female mice were ovariectomized and underwent drill-hole defect surgery (Day 0) on the right tibial diaphysis at 11 weeks of age. The mice underwent one of three regimens starting from Day 1 for 5 days/week: continuous WBV at 45 Hz and 0.3 g for 7.5 min/day (cWBV); 3-s bouts of WBV at 45 Hz, 0.3 g followed by 9-s rest intervals, repeated for 30 min/day (repeated bouts of whole-body vibration with short rest intervals [rWBV]); or a sham treatment. Both the cWBV and rWBV groups received a total of 20,250 vibration cycles per day. On either Day 7 or 14 posteuthanasia (n = 6/group/timepoint), the bone and angiogenic vasculature in the defect were computed tomography imaged using synchrotron light. By Day 14, the bone repair was most advanced in the rWBV group, showing a higher bone volume fraction and a more uniform mineral distribution compared with the sham group. The cWBV group exhibited an intermediate level of bone repair between the sham and rWBV groups. The rWBV group had a decrease in large-sized angiogenic vessels, while the cWBV group showed an increase in such vessels. In conclusion, osteoporotic bone repair was enhanced by WBV bouts with short rest intervals, which may potentially be attributed to the improved mechanosensitivity of osteogenic cells and alterations in angiogenic vasculature.

The association between anti-diabetic agents and osteoporosis, sarcopenia, and osteosarcopenia among Iranian older adults; Bushehr Elderly Health (BEH) program

PURPOSE

Various risk factors are mentioned for osteoporosis, sarcopenia, and osteosarcopenia. Our aim is to assess the impacts of anti-diabetic drugs on these disorders.

METHODS

To perform this study, the participants' data was extracted from the Bushehr Elderly Health (BEH) program in Iran. Afterward, the data were categorized into three subgroups: osteoporosis, sarcopenia, and osteosarcopenia, based on WHO and European Working Group on Sarcopenia in Older People (EWGSOP-2) working group definitions. Demographic characteristics, anthropometric measures, past medical history, and current medications were recorded. Pearson chi-squared and simple/multiple logistic regression using Python (3.11.4) and R (4.3.1) programming software assessed the association between anti-diabetic agents and these bone disorders.

RESULTS

Out of 1995 participants, 820, 848, and 404 had osteoporosis, sarcopenia, or osteosarcopenia, respectively. Among all types of anti-diabetic drugs, a significant protective association between osteoporosis and consumption of second-generation sulfonylureas was found; Adjusted Odd Ratio (AOR) = 0.65 ([95% CI: 0.45-0.94], p-value = 0.023). No associations were found between sarcopenia and consumption of anti-diabetic agents. A significant association was observed between using Meglitinides and the risk of osteosarcopenia; AOR = 4.98 ([95% CI: 1.5-16.55], p-value = 0.009).

CONCLUSION

In conclusion, a protective association between consumption of second-generation sulfonylureas and osteoporosis was found. Moreover, a positive association was found between the consumption of meglitinides and osteosarcopenia. However, to support these findings, further studies are recommended.

Identification of Transcripts with Shared Roles in the Pathogenesis of Postmenopausal Osteoporosis and Cardiovascular Disease

Epidemiological evidence suggests existing comorbidity between postmenopausal osteoporosis (OP) and cardiovascular disease (CVD), but identification of possible shared genes is lacking. The skeletal global transcriptomes were analyzed in trans-iliac bone biopsies (n = 84) from clinically well-characterized postmenopausal women (50 to 86 years) without clinical CVD using microchips and RNA sequencing. One thousand transcripts highly correlated with areal bone mineral density (aBMD) were further analyzed using bioinformatics, and common genes overlapping with CVD and associated biological mechanisms, pathways and functions were identified. Fifty genes (45 mRNAs, 5 miRNAs) were discovered with established roles in oxidative stress, inflammatory response, endothelial function, fibrosis, dyslipidemia and osteoblastogenesis/calcification. These pleiotropic genes with possible CVD comorbidity functions were also present in transcriptomes of microvascular endothelial cells and cardiomyocytes and were differentially expressed between healthy and osteoporotic women with fragility fractures. The results were supported by a genetic pleiotropy-informed conditional False Discovery Rate approach identifying any overlap in single nucleotide polymorphisms (SNPs) within several genes encoding aBMD- and CVD-associated transcripts. The study provides transcriptional and genomic evidence for genes of importance for both BMD regulation and CVD risk in a large collection of postmenopausal bone biopsies. Most of the transcripts identified in the CVD risk categories have no previously recognized roles in OP pathogenesis and provide novel avenues for exploring the mechanistic basis for the biological association between CVD and OP.

Design, synthesis and biological evaluation of novel pyrimidine derivatives as bone anabolic agents promoting osteogenesis via the BMP2/SMAD1 signaling pathway

Anti-resorptive inhibitors such as bisphosphonates are widely used but they have limited efficacy and serious side effects. Though subcutaneous injection of teriparatide [PTH (1-34)] is an effective anabolic therapy, long-term repeated subcutaneous administration is not recommended. Henceforth, orally bio-available small-molecule-based novel therapeutics are unmet medical needs to improve the treatment. In this study, we designed, synthesized, and carried out a biological evaluation of 31 pyrimidine derivatives as potent bone anabolic agents. A series of in vitro experiments confirmed N-(5-bromo-4-(4-bromophenyl)-6-(2,4,5-trimethoxyphenyl)pyrimidin-2-yl)hexanamide (18a) as the most efficacious anabolic agent at 1 pM. It promoted osteogenesis by upregulating the expression of osteogenic genes (RUNX2 and type 1 col) via activation of the BMP2/SMAD1 signaling pathway. In vitro osteogenic potential was further validated using an in vivo fracture defect model where compound 18a promoted the bone formation rate at 5 mg kg-1. We also established the structure-activity relationship and pharmacokinetic studies of 18a.

Whole egg consumption in relation to bone health of the US population: a cross-sectional study

Osteoporosis, a condition that is characterized by low bone mineral density (BMD), is a serious health concern worldwide. This study aims to explore the relationship between whole egg consumption and BMD levels in the US population. This study involves 19 208 participants with valid BMD and egg consumption data from the National Health and Nutrition Examination Survey (NHANES) during 2005-2006, 2007-2008, 2009-2010, 2013-2014 and 2017-2018. Linear regression analysis was conducted to evaluate the association between whole egg consumption and BMD levels. Mediation analysis was used to investigate the role of serum alkaline phosphatase (ALP) in the above relationship. After multivariate adjustment, participants consuming whole eggs over 3.53 ounce per day in their diet were found to have elevated BMD levels in the femur (0.013 g cm-2 with 95% CI: 0.004, 0.022) and lumbar spine (0.013 g cm-2 with 95% CI: 0.002, 0.024) (Ptrend < 0.05). The additive interaction of egg consumption and body mass index (BMI) on the BMD of both the femur and lumbar spine (Pinteraction < 0.05) was also analyzed. The association between whole egg consumption and BMD of both the femur and lumbar spine were significantly mediated by ALP with 71.8% and 83.3% mediation proportion, respectively. In general, higher whole egg consumption is positively related to an increase in the BMD scores of both the femur and lumbar spine among the US population.

Bone Fracture-healing Properties and UPLC-MS Analysis of an Enriched Flavonoid Fraction from Oxystelma esculentum

Oxystelma esculentum has been used as a folk medicine to treat jaundice, throat infections, and skin problems. In the current study, the bone fracture-healing properties of a flavonoid-enriched fraction (Oxy50-60F) of O. esculentum were investigated in Swiss mice using a drill-hole injury model. Oxy50-60F (1 mg/kg/day, 5 mg/kg/day, and 10 mg/kg/day) was administered orally (from the next day) after a 0.6 mm drill-hole injury in mice femur mid-diaphysis for 7 days and 14 days. Parathyroid hormone (40 µg/kg; 5 times/week) was given subcutaneously as the positive control. Confocal imaging for bone regeneration, micro-architecture of femur bones, ex vivo mineralization, hematoxyline and eosin staining, measurement of reactive oxygen species, and gene expression of osteogenic and anti-inflammatory genes were studied. Quercetin, kaempferol, and isorhamnetin glycosides were identified in the active fraction using mass spectrometry techniques. Our results confirm that Oxy50-60F treatment promotes fracture healing and callus formation at drill-hole sites and stimulates osteogenic and anti-inflammatory genes. Oxy50-60F administration to fractured mice exhibited significantly better micro-CT parameters in a dose-dependent manner and promoted nodule mineralization at days 7 and 14 post-injury. Oxy50-60F also prevents ROS generation by increasing expression of the SOD2 enzyme. Overall, this study reveals that Oxy50-60F has bone regeneration potential in a cortical bone defect model, which supports its use in delayed-union and non-union fracture cases.

Design, Synthesis, and Anti-Osteoporotic Characterization of Arginine N-Glycosylated Teriparatide Analogs via the Silver-catalyzed Solid-Phase Glycosylation Strategy

In spite of effective antiosteoporosis potency, teriparatide, a bone-building agent approved by the FDA (Food and Drug Administration), was proven to exhibit various side effects. In our previous work, we developed a universal strategy for synthesizing arginine N-glycosylated peptides termed silver-promoted solid-phase glycosylation (SSG) strategy. However, it is unknown whether the SSG strategy can be applied in the peptide drug design. Herein, we first reported the optimization of teriparatide via SSG strategy. Using Arg20 and/or Arg25 as the modifying positions, three series of arginine N-glycosylated teriparatide analogs were successfully synthesized, of which the introduced sugar groups included glucose, galactose, mannose, rhamnose, ribose, 2-acetamino-2-deoxy-glucose, xylose, lactose, and maltose. Among the 27 arginine N-glycosylated derivatives, Arg20-xylose and Arg25-maltose teriparatide analogs, termed PTH-1g and PTH-2i, respectively, indicated enhanced serum stability and significantly improved antiosteoporotic activities in vitro and in vivo compared with the native counterpart. They may serve as effective therapeutic candidates for treating osteoporosis.

Who was at risk of trauma-related injuries during the COVID-19 pandemic? A retrospective study from a level 1 trauma centre in Switzerland

INTRODUCTION

During the first wave of the COVID-19 pandemic, increasingly strict restrictions were imposed on the activities of the Swiss population, with a peak from 21 March to 27 April 2020. Changes in trauma patterns during the pandemic and the lockdown have been described in various studies around the world, and highlight some particularly exposed groups of people. The objective of this study was to assess changes in trauma-related presentations to the emergency department (ED) during the first wave of the COVID-19 pandemic, as compared to the same period in the previous year, with a particular focus on vulnerable populations.

MATERIALS AND METHODS

All trauma-related admissions to our ED in the first half of 2019 and 2020 were included. Patient demographics, trauma mechanism, affected body region, injury severity and discharge type were extracted from our hospital information system. Trauma subpopulations, such as interpersonal violence, self-inflicted trauma, geriatric trauma and sports-related trauma were analysed.

RESULTS

A total of 5839 ED presentations were included in our study, of which 39.9% were female. Median age was 40 years (interquartile range: 27-60). In comparison to 2019, there was a 15.5% decrease in trauma-related ED presentations in the first half of 2020. This decrease was particularly marked in the 2-month March/April period, with a drop of 36.8%. In 2020, there was a reduction in injuries caused by falls of less than 3 metres or by mechanical force. There was a marked decrease in sports-related trauma and an increase in injuries related to pedal cycles. Geriatric trauma, self-harm and assault-related injuries remained stable.

CONCLUSION

This study described changes in trauma patterns and highlighted populations at risk of trauma during the pandemic in Switzerland in the context of previous international studies.These results may contribute to resource management in a future pandemic.

Sequential Therapy for the Long-Term Treatment of Postmenopausal Osteoporosis

Osteoporosis is a chronic condition characterized by decreased bone mass, loss of skeletal integrity, and increased susceptibility to fracture. Drugs used to treat osteoporosis can be classified as those that block bone resorption (antiresorptive), stimulate bone formation (anabolic), or do both. While all currently approved medications reduce the risk of fragility fractures in high-risk populations, they are generally unable to fully restore bone strength in most patients with established disease. Thus, the majority of patients require disease management over many years. Unfortunately, the continuous use of a single drug has limitations, both in terms of efficacy and safety, and so sequential therapy is commonly required. Given the expanding list of pharmacological agents currently available, careful consideration needs to be given as to which drugs to use and in what sequence. This review will evaluate the differential effects of antiresorptive, bone-forming, and dual-acting drugs when used in specific sequences and will explore the current evidence favoring the initial use of bone-forming/dual-acting drugs followed by antiresorptive medications. This review will also examine the notion that long-term treatment with an antiresorptive drug may diminish the efficacy of subsequent treatment with a bone-forming/dual-acting drug. Finally, this review will explore the current evidence pertaining to the specific issue of how to best prevent the clinical ramifications of denosumab cessation.

Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases

OBJECTIVE

Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti-rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population.

METHODS

A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90-101 years) at the time of operation. The average duration of follow-up was 29.7 months (range 1-120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan-Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow-up period into 1-12 months (short-term), 13-42 months (medium-term) and 43-120 months (long-term) according to the configurations of Kaplan-Meier survival curves.

RESULTS

Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1- to 60-month cumulative all-cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium-term (p = 0.01), while similar survival rates were observed in the short- and long-term post-operation periods (both p > 0.05). Cox regression with survival-time-dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium-term (p = 0.039).

CONCLUSION

Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium-term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.

Towards Improved Identification of Vertebral Fractures in Routine Computed Tomography (CT) Scans: Development and External Validation of a Machine Learning Algorithm

Vertebral fractures (VFs) are the hallmark of osteoporosis, being one of the most frequent types of fragility fracture and an early sign of the disease. They are associated with significant morbidity and mortality. VFs are incidentally found in one out of five imaging studies, however, more than half of the VFs are not identified nor reported in patient computed tomography (CT) scans. Our study aimed to develop a machine learning algorithm to identify VFs in abdominal/chest CT scans and evaluate its performance. We acquired two independent data sets of routine abdominal/chest CT scans of patients aged 50 years or older: a training set of 1011 scans from a non-interventional, prospective proof-of-concept study at the Universitair Ziekenhuis (UZ) Brussel and a validation set of 2000 subjects from an observational cohort study at the Hospital of Holbaek. Both data sets were externally reevaluated to identify reference standard VF readings using the Genant semiquantitative (SQ) grading. Four independent models have been trained in a cross-validation experiment using the training set and an ensemble of four models has been applied to the external validation set. The validation set contained 15.3% scans with one or more VF (SQ2-3), whereas 663 of 24,930 evaluable vertebrae (2.7%) were fractured (SQ2-3) as per reference standard readings. Comparison of the ensemble model with the reference standard readings in identifying subjects with one or more moderate or severe VF resulted in an area under the receiver operating characteristic curve (AUROC) of 0.88 (95% confidence interval [CI], 0.85-0.90), accuracy of 0.92 (95% CI, 0.91-0.93), kappa of 0.72 (95% CI, 0.67-0.76), sensitivity of 0.81 (95% CI, 0.76-0.85), and specificity of 0.95 (95% CI, 0.93-0.96). We demonstrated that a machine learning algorithm trained for VF detection achieved strong performance on an external validation set. It has the potential to support healthcare professionals with the early identification of VFs and prevention of future fragility fractures. © 2023 UCB S.A. and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

The Sequential Therapy in Osteoporosis

Background

Osteoporosis management often involves a sequential treatment approach to optimize patient outcomes and minimize fracture risks. This strategy is tailored to individual patient characteristics, treatment responses, and fracture risk profiles.

Methods

A thorough literature review was systematically executed using prominent databases, including PubMed and EMBASE. The primary aim was to identify original articles and clinical trials evaluating the effectiveness of sequential therapy with anti-osteoporosis drugs, focusing on the period from 1995 to 2023. The analysis encompassed an in-depth examination of osteoporosis drugs, delineating their mechanisms of action, side effects, and current trends as elucidated in the literature.

Results and Discussion

Our study yielded noteworthy insights into the optimal sequencing of pharmacologic agents for the long-term treatment of patients necessitating multiple drugs. Notably, the achievement of optimal improvements in bone mass is observed when commencing treatment with an anabolic medication, followed by the subsequent utilization of an antiresorptive drug. This stands in contrast to initiating therapy with a bisphosphonate, which may potentially diminish outcomes in the post-anabolic intervention period. Furthermore, it has been discerned that caution should be exercised against transitioning from denosumab to PTH homologs due to the adverse effects of heightened bone turnover and sustained weakening of bone structure. Despite the absence of fracture data substantiating the implementation of integrated anabolic/antiresorptive pharmacotherapy, the incorporation of denosumab and teriparatide presents a potential avenue worthy of consideration for individuals at a heightened vulnerability to fragility fractures.

Conclusions

A judiciously implemented sequential treatment strategy in osteoporosis offers a flexible and tailored approach to address diverse clinical scenarios, optimizing fracture prevention and patient outcomes.

Loss of Nmp4 enhances bone gain from sclerostin antibody administration

Severe osteoporosis is often treated with one of three Food and Drug Administration (FDA)-approved osteoanabolics. These drugs act by (1) parathyroid hormone (PTH) receptor stimulation using analogues to PTH (teriparatide) or PTH-related peptide (abaloparatide) or by (2) monoclonal antibody neutralization of sclerostin, an innate Wnt inhibitor (Scl-mAb, romosozumab-aqqg). The efficacies of both strategies wane over time. The transcription factor Nmp4 (Nuclear Matrix Protein 4) is expressed in all tissues yet mice lacking this gene are healthy and exhibit enhanced PTH-induced bone formation. Conditional deletion of Nmp4 in mesenchymal stem progenitor cells (MSPCs) phenocopies the elevated response to PTH in global Nmp4-/- mice. However, targeted deletion in later osteoblast stages does not replicate this response. In this study we queried whether loss of Nmp4 improves Scl-mAb potency. Experimental cohorts included global Nmp4-/- and Nmp4+/+ littermates and three conditional knockout models. Nmp4-floxed (Nmp4fl/fl) mice were crossed with mice harboring one of three Cre-drivers (i) Prx1Cre+ targeting MSPCs, (ii) BglapCre+ (mature osteocalcin-expressing osteoblasts), and (iii) Dmp1Cre+ (osteocytes). Female mice were treated with Scl-mAb or 0.9 % saline vehicle for 4 or 7 weeks from 10 weeks of age. Skeletal response was assessed using micro-computed tomography, dual-energy X-ray absorptiometry, bone histomorphometry, and serum analysis. Global Nmp4-/- mice exhibited enhanced Scl-mAb-induced increases in trabecular bone in the femur and spine and a heightened increase in whole body areal bone mineral density compared to global Nmp4+/+ controls. This improved Scl-mAb potency was primarily driven by enhanced increases in bone formation. Nmp4fl/fl;PrxCre+ mice showed an exaggerated Scl-mAb-induced increase in femoral bone but not in the spine since Prrx1 is not expressed in vertebra. The Nmp4fl/fl;BglapCre+ and Nmp4fl/fl;Dmp1Cre+ mice did not exhibit an improved Scl-mAb response. We conclude that Nmp4 expression in MSPCs interferes with the bone anabolic response to anti-sclerostin therapy.

Nrf2: A promising therapeutic target in bone-related diseases

Nuclear factor erythroid-2-related factor 2 (Nrf2) plays an important role in maintaining cellular homeostasis, as it suppresses cell damage caused by external stimuli by regulating the transcription of intracellular defense-related genes. Accumulating evidence has highlighted the crucial role of reduction-oxidation (REDOX) imbalance in the development of bone-related diseases. Nrf2, a transcription factor linked to nuclear factor-erythrocyte 2, plays a pivotal role in the regulation of oxidative stress and induction of antioxidant defenses. Therefore, further investigation of the mechanism and function of Nrf2 in bone-related diseases is essential. Considerable evidence suggests that increased nuclear transcription of Nrf2 in response to external stimuli promotes the expression of intracellular antioxidant-related genes, which in turn leads to the inhibition of bone remodeling imbalance, improved fracture recovery, reduced occurrence of osteoarthritis, and greater tumor resistance. Certain natural extracts can selectively target Nrf2, potentially offering therapeutic benefits for osteogenic arthropathy. In this article, the biological characteristics of Nrf2 are reviewed, the intricate interplay between Nrf2-regulated REDOX imbalance and bone-related diseases is explored, and the potential preventive and protective effects of natural products targeting Nrf2 in these diseases are elucidated. A comprehensive understanding of the role of Nrf2 in the development of bone-related diseases provides valuable insights into clinical interventions and can facilitate the discovery of novel Nrf2-targeting drugs.

Global Epidemiology of Hip Fractures: Secular Trends in Incidence Rate, Post-Fracture Treatment, and All-Cause Mortality

In this international study, we examined the incidence of hip fractures, postfracture treatment, and all-cause mortality following hip fractures, based on demographics, geography, and calendar year. We used patient-level healthcare data from 19 countries and regions to identify patients aged 50 years and older hospitalized with a hip fracture from 2005 to 2018. The age- and sex-standardized incidence rates of hip fractures, post-hip fracture treatment (defined as the proportion of patients receiving anti-osteoporosis medication with various mechanisms of action [bisphosphonates, denosumab, raloxifene, strontium ranelate, or teriparatide] following a hip fracture), and the all-cause mortality rates after hip fractures were estimated using a standardized protocol and common data model. The number of hip fractures in 2050 was projected based on trends in the incidence and estimated future population demographics. In total, 4,115,046 hip fractures were identified from 20 databases. The reported age- and sex-standardized incidence rates of hip fractures ranged from 95.1 (95% confidence interval [CI] 94.8-95.4) in Brazil to 315.9 (95% CI 314.0-317.7) in Denmark per 100,000 population. Incidence rates decreased over the study period in most countries; however, the estimated total annual number of hip fractures nearly doubled from 2018 to 2050. Within 1 year following a hip fracture, post-hip fracture treatment ranged from 11.5% (95% CI 11.1% to 11.9%) in Germany to 50.3% (95% CI 50.0% to 50.7%) in the United Kingdom, and all-cause mortality rates ranged from 14.4% (95% CI 14.0% to 14.8%) in Singapore to 28.3% (95% CI 28.0% to 28.6%) in the United Kingdom. Males had lower use of anti-osteoporosis medication than females, higher rates of all-cause mortality, and a larger increase in the projected number of hip fractures by 2050. Substantial variations exist in the global epidemiology of hip fractures and postfracture outcomes. Our findings inform possible actions to reduce the projected public health burden of osteoporotic fractures among the aging population. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Cost-effectiveness and willing-to-pay thresholds for vertebral augmentation of osteoporotic vertebral fractures, what are they based on: a systematic review

OBJECTIVE

Although there is substantial clinical evidence on the safety and effectiveness of vertebral augmentation for osteoporotic vertebral fractures, cost-effectiveness is less well known. The objective of this study is to provide a systematic review of cost-effectiveness studies and policy-based willingness-to-pay (WTP) thresholds for different vertebral augmentation (VA) procedures, vertebroplasty (VP) and balloon kyphoplasty (BK), for osteoporotic vertebral fractures (OVFs).

DESIGN

A systematic review targeting cost-effectiveness studies of VA procedures for OVFs.

DATA SOURCES

Six bibliographic databases were searched from inception up to May 2021.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Studies were eligible if meeting all predefined criteria: (1) VP or BK intervention, (2) OVFs and (3) cost-effectiveness study. Articles not written in English, abstracts, editorials, reviews and those reporting only cost data were excluded.

DATA EXTRACTION AND SYNTHESIS

Information was extracted on study characteristics, cost-effective estimates, summary decisions and payer WTP thresholds. Incremental cost-effective ratio (ICER) was the main outcome measure. Studies were summarised by a structured narrative synthesis organised by comparisons with conservative management (CM). Two independent reviewers assessed the quality (risk of bias) of the systematic review and cost-effectiveness studies by peer-reviewed checklists.

RESULTS

We identified 520 references through database searching and 501 were excluded as ineligible by titles and abstract. Ten reports were identified as eligible from 19 full-text reviews. ICER for VP versus CM evaluated as cost per quality-adjusted life-year (QALY) ranged from €22 685 (*US$33 395) in Netherlands to £-2240 (*US$-3273), a cost-saving in the UK. ICERs for BK versus CM ranged from £2706 (*US$3954) in UK to kr600 000 (*US$90 910) in Sweden. ICERs were within payer WTP thresholds for a QALY based on historical benchmarks.

CONCLUSIONS

Both VP and BK were judged cost-effective alternatives to CM for OVFs in economic studies and were within WTP thresholds in multiple healthcare settings.

The bone-protective benefits of amino-conjugated calcium in an ovariectomized (OVX) rat model

Low bone density, fragility, and microarchitectural disintegration are the symptoms of osteoporosis. An imbalance between bone growth and resorption can lead to osteoporosis. This study evaluated the effects of amino-calcium (AC) on bone protection in ovariectomized control group (NC) rats. Amino-calcium (AC) was characterized using Fourier-transform infrared spectroscopy (FT-IR), energy-dispersive X-ray spectroscopy (EDS), and nuclear magnetic resonance spectroscopy analyses (NMR). After determining the biocompatibility of amino-calcium (AC) with MC3T3-E1 cells, alkaline phosphatase staining revealed significant changes on day 7. Three of the four groups underwent ovariectomy, whereas one group received a placebo. On micro-computed tomography, in vivo, data showed increased bone volume fraction in the femoral head and shaft areas in the amino-calcium (AC) group. Hematoxylin and eosin staining showed a bone mass and architectural protection in the amino-calcium (AC) group compared with the calcium carbonate and OVX control group. RNA sequencing analysis revealed high expression of osteogenesis-related genes in MC3T3-E1 cells. RNA sequencing revealed a significant fold change in the expression of integrin-binding sialoprotein (IBSP), bone gamma-carboxyglutamate proteins 1 and 2(BGLAP1 and BGLAP2), and periostin (POSTN). The study concluded that supplementing the OVX rats with calcium enhanced bone protection.

Direct anterior versus antero-lateral approach in hip joint hemiarthroplasty

BACKGROUND

Femoral neck fractures are common injuries in the elderly and represent a major source of morbidity and mortality. Due to the benefits, bipolar hip hemiarthroplasty (BHH) is a popular method to treat. The purpose of this study is to evaluate the functional and radiographic outcomes for BHH comparing the direct anterior approach (DAA) to the anterolateral approach (ALA) to the hip joint.

METHODS

We used a prospective, randomized observational study design, where we enrolled 83 patients at a level-I-trauma center presenting with indication for BHH. We followed up the participants at defined intervals over a period of 1 year. The follow-up examinations were carried out at defined time intervals for a period of 1 year. Calculations were performed with Statistical Package for Social Sciences (SPSS) 21.0.

RESULTS

Concerning postoperative pain sensation, the anterior group had statistically significantly decreased pain levels at one (p = 0.02), seven (p = 0.04) and 14 days (p = 0.02) following the intervention when compared to the ALA sample. The postoperative modified Barthel-Index showed a statistically significant difference on the first postoperative day at the anterior group.

CONCLUSION

Although we compared two minimally invasive approaches, our results shows a statistically significant difference in pain intensity and mobility for the early postoperative period using the direct anterior approach.

NMP4, an Arbiter of Bone Cell Secretory Capacity and Regulator of Skeletal Response to PTH Therapy

The skeleton is a secretory organ, and the goal of some osteoporosis therapies is to maximize bone matrix output. Nmp4 encodes a novel transcription factor that regulates bone cell secretion as part of its functional repertoire. Loss of Nmp4 enhances bone response to osteoanabolic therapy, in part, by increasing the production and delivery of bone matrix. Nmp4 shares traits with scaling factors, which are transcription factors that influence the expression of hundreds of genes to govern proteome allocation for establishing secretory cell infrastructure and capacity. Nmp4 is expressed in all tissues and while global loss of this gene leads to no overt baseline phenotype, deletion of Nmp4 has broad tissue effects in mice challenged with certain stressors. In addition to an enhanced response to osteoporosis therapies, Nmp4-deficient mice are less sensitive to high fat diet-induced weight gain and insulin resistance, exhibit a reduced disease severity in response to influenza A virus (IAV) infection, and resist the development of some forms of rheumatoid arthritis. In this review, we present the current understanding of the mechanisms underlying Nmp4 regulation of the skeletal response to osteoanabolics, and we discuss how this unique gene contributes to the diverse phenotypes among different tissues and stresses. An emerging theme is that Nmp4 is important for the infrastructure and capacity of secretory cells that are critical for health and disease.

Cost-Effectiveness Analysis of CT-Based Finite Element Modeling for Osteoporosis Screening in Secondary Fracture Prevention: An Early Health Technology Assessment in the Netherlands

Objective. To conduct cost-utility analyses for Computed Tomography To Strength (CT2S), a novel osteoporosis screening service, compared with dual-energy X-ray absorptiometry (DXA), treat all without screening, and no screening methods for Dutch postmenopausal women referred to fracture liaison service (FLS). CT2S uses CT scans to generate femur models and simulate sideways fall scenarios for bone strength assessment. Methods. Early health technology assessment (HTA) was adopted to evaluate CT2S as a novel osteoporosis screening tool for secondary fracture prevention. We constructed a 2-dimensional simulation model considering 4 strategies (no screening, treat all without screening, DXA, CT2S) together with screening intervals (5 y, 2 y), treatments (oral alendronate, zoledronic acid), and discount rate scenarios among Dutch women in 3 age groups (60s, 70s, and 80s). Strategy comparisons were based on incremental cost-effectiveness ratios (ICERs), considering an ICER below €20,000 per QALY gained as cost-effective in the Netherlands. Results. Under the base-case scenario, CT2S versus DXA had estimated ICERs of €41,200 and €14,083 per QALY gained for the 60s and 70s age groups, respectively. For the 80s age group, CT2S was more effective and less costly than DXA. Changing treatment from weekly oral alendronate to annual zoledronic acid substantially decreased CT2S versus DXA ICERs across all age groups. Setting the screening interval to 2 y increased CT2S versus DXA ICERs to €100,333, €55,571, and €15,750 per QALY gained for the 60s, 70s, and 80s age groups, respectively. In all simulated populations and scenarios, CT2S was cost-effective (in some cases dominant) compared with the treat all strategy and cost-saving (more effective and less costly) compared with no screening. Conclusion. CT2S was estimated to be potentially cost-effective in the 70s and 80s age groups considering the willingness-to-pay threshold of the Netherlands. This early HTA suggests CT2S as a potential novel osteoporosis screening tool for secondary fracture prevention.

Highlights

For postmenopausal Dutch women who have been referred to the FLS, direct access to CT2S may be cost-effective compared with DXA for age groups 70s and 80s, when considering the ICER threshold of the Netherlands. This study positions CT2S as a potential novel osteoporosis-screening tool for secondary fracture prevention in the clinical setting.A shorter screening interval of 2 y increases the effectiveness of both screening strategies, but the ICER of CT2S compared with DXA also increased substantially, which made CT2S no longer cost-effective for the 70s age group; however, it remains cost-effective for individuals in their 80s.Annual zoledronic acid treatment with better adherence may contribute to a lower cost-effectiveness ratio when comparing CT2S to DXA screening and the treat all strategies for all age groups.

Systems modelling as an approach for eliciting the mechanisms for hip fracture recovery among older adults in a participatory stakeholder engagement setting

Introduction

Due to an aging population, the rising prevalence and incidence of hip fractures and the associated health and economic burden present a challenge to healthcare systems worldwide. Studies have shown that a complex interplay of physiological, psychological, and social factors often affects the recovery trajectories of older adults with hip fractures, often complicating the recovery process.

Methods

This research aims to actively engage stakeholders (including doctors, physiotherapists, hip fracture patients, and caregivers) using the systems modeling methodology of Group Model Building (GMB) to elicit the factors that promote or inhibit hip fracture recovery, incorporating a feedback perspective to inform system-wide interventions. Hip fracture stakeholder engagement was facilitated through the Group Model Building approach in a two-half-day workshop of 25 stakeholders. This approach combined different techniques to develop a comprehensive qualitative whole-system view model of the factors that promote or inhibit hip fracture recovery.

Results

A conceptual, qualitative model of the dynamics of hip fracture recovery was developed that draws on stakeholders' personal experiences through a moderated interaction. Stakeholders identified four domains (i.e., expectation formation, rehabilitation, affordability/availability, and resilience building) that play a significant role in the hip fracture recovery journey..

Discussion

The insight that recovery of loss of function due to hip fracture is attributed to (a) the recognition of a gap between pre-fracture physical function and current physical function; and (b) the marshaling of psychological resilience to respond promptly to a physical functional loss via uptake of rehabilitation services is supported by findings and has several policy implications.

Osteoporosis treatment gap in patients at risk of fracture in Egypt: a multi-center, cross-sectional observational study

Despite the wide availability of a wide variety of approved osteoporosis medications and DXA scan centers in Egypt, only a minority of patients at high risk of sustaining a fragility fracture receive treatment, even after their first fracture. Such big "treatment gap" leaves the most high-risk individuals unprotected against fragility fractures. This study provides a benchmark to monitor national trends in osteoporosis management and service uptake.

PURPOSE

To assess the treatment gap among men and postmenopausal women presenting with a fragility fracture, and to analyze the characteristics and fracture risks of the patients presenting with an index fragility fracture.

METHODS

This was a multi-center, cross-sectional, observational study. Both men and postmenopausal women, admitted with an osteoporotic fracture (whether major osteoporosis or hip fracture), were consecutively recruited for this work. The fracture risk was assessed based on their FRAX calculation prior to the index fracture. All the patients were assessed for their falls and sarcopenia risks. Blood tests for bone profile as well as DXA scan were offered to all the patients.

RESULTS

Two hundred and thirty-six patients presenting with fragility fractures were included in this work. 70.8% were women and 29.2% were men. Mean age was 70.1 (SD = 9.2) years. Ten-year probability of fracture (without BMD) was high in 65.9% of the postmenopausal women and 40.3% of the men. 82.1% of the postmenopausal women and 100% in men identified to be eligible for osteoporosis therapy did not receive any form of osteoporosis therapy. FRAX score correlated significantly with bone mineral density assessment at both hip and spine. Falls, sarcopenia, and functional disability showed significant relation to the fracture risk.

CONCLUSIONS

There is a large treatment gap in Egyptian older adults. The recent guidelines for osteoporosis management in Egypt endorsed fracture centric approach to identify people at risk. The gap appears to be related to a low rate of osteoporosis diagnosis and lack of patient education.

Functional autonomy and 12-month mortality in older adults with proximal femoral fractures in an orthogeriatric setting: risk factors and gender differences

BACKGROUND

Proximal femur fractures have a negative impact on loss of functional autonomy and mortality.

OBJECTIVE

The aim of this retrospective study was to evaluate functional autonomy and mortality in a group of older adults with hip fractures managed in an orthogeriatric setting 12 months after discharge and to determine if gender affected outcome.

METHODS

In all participants, we assessed clinical history, functional pre-fracture status using activities of daily living (ADL) and in-hospital details. At 12 months after discharge, we evaluated functional status, place of residence, hospital readmissions and mortality.

RESULTS

We studied 361 women and 124 men and we observed a significant reduction in the ADL score at 6 months (1.15 ± 1.58/p < 0.001 in women and 1.45 ± 1.66/p < 0.001 in men). One-year mortality (33.1% in men and 14.7% in women) was associated with pre-fracture ADL score and reduction in ADL at 6 months (HR 0.68/95%, CI 0.48-0.97/p < 0.05 and HR 1.70/95%, CI 1.17-2.48/p < 0.01, respectively) in women, and new hospitalisations at 6 months and polypharmacy in men (HR 1.65/95%, CI 1.07-2.56/p < 0.05 and HR 1.40/95%, CI 1.00-1.96/p = 0.05, respectively) in Cox's regression model.

DISCUSSION AND CONCLUSIONS

Our study suggests that functional loss in older adults hospitalised for proximal femur fractures is greatest in the first 6 months after discharge, and this increases the risk of death at 1 year. Cumulative mortality at 12 months is higher in men and appears to be related to polypharmacy and new hospital admissions 6 months after discharge.

Differential Expression of Non-Coding RNAs in Stem Cell Development and Therapeutics of Bone Disorders

Stem cells' self-renewal and multi-lineage differentiation are regulated by a complex network consisting of signaling factors, chromatin regulators, transcription factors, and non-coding RNAs (ncRNAs). Diverse role of ncRNAs in stem cell development and maintenance of bone homeostasis have been discovered recently. The ncRNAs, such as long non-coding RNAs, micro RNAs, circular RNAs, small interfering RNA, Piwi-interacting RNAs, etc., are not translated into proteins but act as essential epigenetic regulators in stem cells' self-renewal and differentiation. Different signaling pathways are monitored efficiently by the differential expression of ncRNAs, which function as regulatory elements in determining the fate of stem cells. In addition, several species of ncRNAs could serve as potential molecular biomarkers in early diagnosis of bone diseases, including osteoporosis, osteoarthritis, and bone cancers, ultimately leading to the development of new therapeutic strategies. This review aims to explore the specific roles of ncRNAs and their effective molecular mechanisms in the growth and development of stem cells, and in the regulation of osteoblast and osteoclast activities. Furthermore, we focus on and explore the association of altered ncRNA expression with stem cells and bone turnover.

Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years

BACKGROUND

Accurate estimation of the imminent fragility fracture risk currently represents a challenging task. The novel Fragility Score (FS) parameter, obtained during a Radiofrequency Echographic Multi Spectrometry (REMS) scan of lumbar or femoral regions, has been developed for the non-ionizing estimation of skeletal fragility.

AIMS

The aim of this study was to assess the performance of FS in the early identification of patients at risk for incident fragility fractures with respect to bone mineral density (BMD) measurements.

METHODS

Data from 1989 Caucasians of both genders were analysed and the incidence of fractures was assessed during a follow-up period up to 5 years. The diagnostic performance of FS to discriminate between patients with and without incident fragility fracture in comparison to that of the BMD T-scores measured by both Dual X-ray Absorptiometry (DXA) and REMS was assessed through ROC analysis.

RESULTS

Concerning the prediction of generic osteoporotic fractures, FS provided AUC = 0.811 for women and AUC = 0.780 for men, which resulted in AUC = 0.715 and AUC = 0.758, respectively, when adjusted for age and body mass index (BMI). For the prediction of hip fractures, the corresponding values were AUC = 0.780 for women and AUC = 0.809 for men, which became AUC = 0.735 and AUC = 0.758, respectively, after age- and BMI-adjustment. Overall, FS showed the highest prediction ability for any considered fracture type in both genders, resulting always being significantly higher than either T-scores, whose AUC values were in the range 0.472-0.709.

CONCLUSION

FS displayed a superior performance in fracture prediction, representing a valuable diagnostic tool to accurately detect a short-term fracture risk.

Vertebral Augmentation in Spine Surgery

Vertebral augmentation has been a well-studied adjunct percutaneous procedure in spine surgery. Cement augmentation has been used in the treatment of compression fractures through kyphoplasties or vertebroplasties. Historically, data have shown no difference between treating compression fractures conservatively versus with percutaneous cement augmentation procedures. Recent literature has shown improvement in patient outcomes and increase in mobility with percutaneous cement augmentation procedures. Cement augmentation has been used in treating patients with spinal column fractures in higher energy trauma. Cement augmentation has shown to have a reduction in local kyphosis, improved pain, and significant height restoration of the anterior column in patients with burst fractures. Augmentation has been used in spinal deformity surgery, specifically to attempt to reduce the risk of proximal junctional kyphosis and to decrease the risk of screw pullout with cement augmented fenestrated screws in patients with osteoporosis. In pathologic compression fractures, cement augmentation is a safe, viable intervention to improve pain control in these patients. This review will go into the new advances of vertebral augmentation and indications for use in treatment today.

Diagnostic efficacy of radiomorphometric indices for predicting osteoporosis in a Norwegian population in the Tromsø Study: Tromsø7

OBJECTIVE

The aim of this study was to investigate the diagnostic efficacy of the radiomorphometric indices of mandibular cortical width (MCW) and mandibular cortical index (MCI) of cortical erosion for osteoporosis screening in adults (≥40 years) and older adults (≥65 years) to determine whether adding a fracture risk assessment tool (FRAX) would improve efficacy.

STUDY DESIGN

One observer measured MCW and assessed MCI on dental panoramic radiographs acquired for patients in the Tromsø study. These indices, alone and with FRAX scores, were evaluated for efficacy in predicting osteoporosis, which was diagnosed by bone density measurement at the femoral necks with dual-energy X-ray absorptiometry.

RESULTS

MCW ≤3 mm and MCI indicating heavily eroded cortices (C3) had accuracies of 68.8% and 83.6%, respectively, in identifying osteoporosis. In females >65 years, MCW ≤3 mm and C3 produced higher sensitivities but lower specificities, with slightly lower accuracies (61.4% and 79.8%, respectively) compared with all females. The addition of FRAX scores >15% improved the accuracy of MCW ≤3 mm (81.7%) and C3 (87.9%), resulting in high specificity (86.6% and 95.4%). Combining MCW ≤3 mm or C3 with FRAX >15% increased the probabilities of detecting osteoporosis by increasing positive likelihood ratios.

CONCLUSIONS

MCW ≤3 mm or MCI C3, when combined with FRAX >15%, showed superior diagnostic efficacy, with high specificity in detecting females without osteoporosis.

Evaluation of the Association between Low-Density Lipoprotein (LDL) and All-Cause Mortality in Geriatric Patients with Hip Fractures: A Prospective Cohort Study of 339 Patients

BACKGROUND

Many factors affect the prognosis of hip fractures in the elderly. Some studies have suggested a direct or indirect association among serum lipid levels, osteoporosis, and hip fracture risk. LDL levels were found to have a statistically significant nonlinear U-shaped relationship with hip fracture risk. However, the relationship between serum LDL levels and the prognosis of patients with hip fractures remains unclear. Therefore, in this study, we assessed the influence of serum LDL levels on patient mortality over a long-term follow-up period.

METHODS

Elderly patients with hip fractures were screened between January 2015 and September 2019, and their demographic and clinical characteristics were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between LDL levels and mortality. Analyses were performed using Empower Stats and R software.

RESULTS

Overall, 339 patients with a mean follow-up period of 34.17 months were included in this study. Ninety-nine patients (29.20%) died due to all-cause mortality. Linear multivariate Cox regression models showed that LDL levels were associated with mortality (HR = 0.69, 95%CI: 0.53, 0.91, p = 0.0085) after adjusting for confounding factors. However, the linear association was unstable, and nonlinearity was identified. An LDL concentration of 2.31 mmol/L was defined as the inflection point for prediction. A LDL level < 2.31 mmol/L was associated with mortality (HR = 0.42, 95%CI: 0.25, 0.69, p = 0.0006), whereas LDL > 2.31 mmol/L was not a risk factor for mortality (HR = 1.06, 95%CI: 0.70, 1.63, p = 0.7722).

CONCLUSIONS

The preoperative LDL level was nonlinearly associated with mortality in elderly patients with hip fractures, and the LDL level was a risk indicator of mortality. Furthermore, 2.31 mmol/L could be considered a predictor cut-off for risk.

Osteoporosis-related appendicular fractures in Tikur Anbessa Specialized Hospital, Ethiopia: a prospective observational study

We examined the frequency of osteoporotic fractures among patients presenting to Tikur Anbessa Specialized Hospital. Osteoporotic fractures accounted for 10.4% of all fractures and 31.8% of those 40 years and older. In addition, hip fractures accounted for 60%. Therefore, devising strategies for preventing, treating, and rehabilitating osteoporotic fractures is critical.

PURPOSE

Examine the frequency of osteoporotic fractures among patients presenting to Tikur Anbessa Specialized Hospital.

METHODS

This is an observational study of prospectively collected data between January 2018 and December 2021. Patients were categorized as having osteoporotic fracture if they were 40 years or older, sustained a low-energy injury, and had characteristic fracture patterns to the hip, proximal humerus, distal radius, tibia (in females only), clavicle, and scapula. A descriptive analysis was carried out to assess patient demographics. Risk factors were then evaluated using a binary logistic regression model.

RESULTS

A total of 4712 orthopedic injury patients presented to the emergency department with 4422 fracture cases. Of these, 461 fulfilled the diagnostic criteria for osteoporotic fractures. The overall rate of osteoporotic fractures was 10.4% of all patients with fractures and 31.8% of those 40 years or older. Overall, 63.3% were female. One in four females and 5% of males with musculoskeletal trauma had an osteoporotic fracture. Osteoporotic hip fractures made up 59.9% of osteoporotic fractures and 5.9% of all fractures, followed by distal radius (23%), tibia in females (8.2%), and proximal humerus (7.4%). Pelvis (2.6%), clavicle (0.9%), and scapula (0.2%) fractures were found to be rare. Among all patients with fractures following low-energy injuries, when patients were aged 50 years and older, there was a higher risk that the trauma resulted in an osteoporotic fracture. This figure was highest among those aged 80 years and older (odds ratio (OR), 11.88; 95% CI, 7.01-20.11).

CONCLUSIONS

Further studies need to be done to show the prevalence of osteoporosis and osteoporotic fractures in Ethiopia and examine risk factors. Devising strategies for preventing, treating, and rehabilitating osteoporotic fractures is critical.

Association between total cholesterol and total bone mineral density in US adults: National Health and Nutrition Examination Survey (NHANES), 2011-2018

BACKGROUND

Accumulated evidence indicates that cholesterol is offensive to bone metabolism. Therefore, we examined the real-world study among total cholesterol and total bone mineral density (BMD). We investigated the relationship between total cholesterol and total BMD among 10,039 US participants aged 20-59 years old over the period 2011-2018 from the NHANES.

METHODS

To analyze the relationship among total cholesterol and total BMD, multivariate linear regression models were used. Fitted smoothing curves, generalized additive models, and threshold effect analysis were also conducted.

RESULTS

After adjusting for additional covariates, weighted multivariable linear regression models indicated total cholesterol concentration levels exhibited a negative relationship with total BMD, particularly among participants aged 20-29 years. Concerning subgroup analysis, stratified by gender, race/ethnicity and age group, the negative correlation of total cholesterol with total BMD dwelled in both female and male as well as in whites and other races (including Hispanic and Multi-Racial), but not in non-Hispanic blacks and Mexican American. In other races, this relationship presented a nonlinear association (inflection point: 6.7 mmol/L) with a U-shaped curve. Among participants aged 40 to 49 years, this relationship also followed a nonlinear association (inflection point: 5.84 mmol/L), indicating a saturation effect. Moreover, the three types of diabetes status were found to have negative, U-shaped, and positive relationships. In participants with borderline diabetes status, the relationship of total cholesterol with total BMD was a U-shaped curve (inflection point: 4.65 mmol/L).

CONCLUSIONS

For US young adults (20-29 years old), our study revealed a negative relationship between total cholesterol and total BMD. This association followed a U-shaped curve (inflection point: 4.65 mmol/L) in borderline diabetes status participants, a saturation curve (inflection point: 5.84 mmol/L) in participants aged 40-49 years and a nonlinear curve (inflection point: 6.7 mmol/L) in other races (including Hispanic and Multi-Racial). Therefore, keeping total cholesterol concentration at a reasonable level for young adults and diabetic population might be an approach to prevent osteoporosis or osteopenia.

Conditional Loss of Nmp4 in Mesenchymal Stem Progenitor Cells Enhances PTH-Induced Bone Formation

Activation of bone anabolic pathways is a fruitful approach for treating severe osteoporosis, yet FDA-approved osteoanabolics, eg, parathyroid hormone (PTH), have limited efficacy. Improving their potency is a promising strategy for maximizing bone anabolic output. Nmp4 (Nuclear Matrix Protein 4) global knockout mice exhibit enhanced PTH-induced increases in trabecular bone but display no overt baseline skeletal phenotype. Nmp4 is expressed in all tissues; therefore, to determine which cell type is responsible for driving the beneficial effects of Nmp4 inhibition, we conditionally removed this gene from cells at distinct stages of osteogenic differentiation. Nmp4-floxed (Nmp4fl/fl ) mice were crossed with mice bearing one of three Cre drivers including (i) Prx1Cre+  to remove Nmp4 from mesenchymal stem/progenitor cells (MSPCs) in long bones; (ii) BglapCre+  targeting mature osteoblasts, and (iii) Dmp1Cre+  to disable Nmp4 in osteocytes. Virgin female Cre+  and Cre- mice (10 weeks of age) were sorted into cohorts by weight and genotype. Mice were administered daily injections of either human PTH 1-34 at 30 μg/kg or vehicle for 4 weeks or 7 weeks. Skeletal response was assessed using dual-energy X-ray absorptiometry, micro-computed tomography, bone histomorphometry, and serum analysis for remodeling markers. Nmp4fl/fl ;Prx1Cre+  mice virtually phenocopied the global Nmp4-/- skeleton in the femur, ie, a mild baseline phenotype but significantly enhanced PTH-induced increase in femur trabecular bone volume/total volume (BV/TV) compared with their Nmp4fl/fl ;Prx1Cre- controls. This was not observed in the spine, where Prrx1 is not expressed. Heightened response to PTH was coincident with enhanced bone formation. Conditional loss of Nmp4 from the mature osteoblasts (Nmp4fl/fl ;BglapCre+ ) failed to increase BV/TV or enhance PTH response. However, conditional disabling of Nmp4 in osteocytes (Nmp4fl/fl ;Dmp1Cre+ ) increased BV/TV without boosting response to hormone under our experimental regimen. We conclude that Nmp4-/- Prx1-expressing MSPCs drive the improved response to PTH therapy and that this gene has stage-specific effects on osteoanabolism. © 2022 American Society for Bone and Mineral Research (ASBMR).

Tea consumption and the risks of osteoporosis and hip fracture: a population-based longitudinal follow-up study

This population-based longitudinal follow-up study showed a protective effect of tea consumption against osteoporosis, particularly among women and middle-aged people. High tea consumption was also associated with a reduced risk of hip fracture.

INTRODUCTION

To investigate the association of tea consumption with the risks of osteoporosis and hip fracture.

METHODS

This study used the Keelung Community-based Integrated Screening database and Taiwan's National Health Insurance Research Database. A total of 42,742 subjects aged 45 to 74 years were enrolled. Each was classified as no tea consumption, low tea consumption, and high tea consumption, according to the results of an eating habits questionnaire. The diagnosis of osteoporosis and hip fracture was based on BMD measured by dual-energy X-ray absorptiometry and the X-ray findings. The median follow-up time was 8.5 years.

RESULTS

As compared with the no tea consumption group, the osteoporosis HRs for the low tea consumption and high tea consumption groups were 0.88 (95% confidence interval (CI) 0.80-0.96) and 0.87 (95% CI 0.80-0.94), respectively. Among those participants aged 59 or below, the osteoporosis HRs for low tea consumption and high tea consumption (vs. no tea consumption) were 0.85 (95% CI 0.74-0.96) and 0.79 (95% CI 0.69-0.90). The HRs of hip fracture for the low tea consumption and high tea consumption groups (vs. no tea consumption) were 0.85 (95% CI 0.67-1.08) and 0.69 (95% CI 0.55-0.86), respectively.

CONCLUSION

Tea consumption was linked to a lower risk of osteoporosis, particularly among women and middle-aged people. High tea consumption was also associated with a reduced risk of hip fracture.

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

Background

Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field.

Purpose

This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline.

Methods

The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations.

Results

Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively.

Conclusions

The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.

Efficacy and safety of acupuncture in combination with Chinese herbal medicine in dealing with osteoporosis: A protocol for a systematic review and network meta-analysis

BACKGROUND

Osteoporosis (OP) has emerged as a major global public health issue due to its high prevalence, unknown pathogenesis, and lack of specific drugs for prevention and treatment. Studies have demonstrated that acupuncture in combination with Chinese herbal medicine (CHM) is effective in treating OP. However, there is a scarcity of experience and high-quality evidence. A network meta-analysis and systematic review were used to evaluate the efficacy and safety of acupuncture in combination with CHM for the treatment of OP.

METHODS

Comprehensive search of Chinese databases such as China National Knowledge Infrastructure, VIP, Wanfang, China Biomedical Literature Database and English databases for example PubMed, Cochrane Library, EMbase, etc. The search period was extended from the creation of the database to November 2022. All randomized controlled trials on acupuncture in combination with CHM in dealing with OP were collected. After literature analysis and data extraction, the Cochrance system was used to evaluate the high quality of the included articles and Stata 14.0 was used for the network meta-analysis.

RESULTS

The current systematic review and network meta-analysis will provide the effectiveness and safety of acupuncture in combination with CHM in dealing with OP.

CONCLUSION

The research will provide reliable evidence for the clinical use of acupuncture in combination with CHM in dealing with OP.

The Potential Economic Benefits of an Alarm Service in Order Communication Systems in Korea: a Cost-Effectiveness Analysis of Less-Intensive Fracture Liaison Services Based on a Prospective Cohort Study

An alarm service in an order communication system (OCS) was found to be effective at increasing the rate of dual-energy X-ray absorptiometry (DXA) testing and treatment in South Korea, but its cost-effectiveness remains unknown. We used a Markov model to determine the cost-effectiveness of the alarm service in the OCS compared to no alarm service for the post-fracture management of subjects aged 50 years and older with fragility fractures. DXA testing and treatment data were collected from a prospective cohort study. The prevalence of osteoporotic fractures, the subsequent risk of hip fracture, and healthcare costs were obtained using Korea National Health Insurance claims data. The lifetime cost and quality-adjusted life-years (QALYs) gained were estimated from a healthcare perspective. A probabilistic sensitivity analysis was performed to examine the uncertainty of the results. The alarm service increased treatment by 125 per 1000 patients and prevented 3 hip fractures per 1000 patients. The alarm service cost an additional 249,393 KRW and resulted in an increase of 0.008 QALYs per patient compared to no alarm service. The incremental cost-effectiveness ratio was 31,174,125 KRW (26,843 USD) per QALY gained. The alarm service was cost-effective than no alarm service if the willingness to pay setting as 1GDP per capita (29,288 USD) per QALY gained. This study shows that less-intensive fracture liaison services, such as an alarm service, are cost-effective for patients aged 50 years and older with osteoporotic fractures in Korea. An intensive model, including enhanced identification and education, could further prevent the risk of refracture and improve cost-effectiveness.

FGF2 positively regulates osteoclastogenesis via activating the ERK-CREB pathway

Fibroblast growth factor 2 (FGF2) plays crucial roles in the growth and development of several tissues. However, its function in bone homeostasis remains controversial. Here, we found that exogenous FGF2 supplementation inhibited the mineralization of bone marrow stromal cells (BMSCs), at least partially, via up-regulating the gene expression of osteoclastogenesis. The FGF receptor (FGFR) allosteric antagonist SSR128129E modestly, whereas the FGFR tyrosine kinase inhibitor AZD4547 significantly antagonized the effects of FGF2. Mechanistically, FGF2 stimulated ERK phosphorylation, and the ERK signaling inhibitor PD325901 strongly blocked FGF2 enhancement of osteoclastogenesis. Moreover, the phosphorylation of CREB was also activated in response to FGF2, thereby potentiating the interaction of p-CREB with the promoter region of Rankl gene. Notably, FGF2-deficient BMSCs exhibited higher mineralization capability and lower osteoclastogenic gene expression. Correspondingly, FGF2-knockout mice showed increased bone mass and attenuated expression of osteoclast-related markers, which were associated with moderate inhibition of the ERK signaling. In conclusion, FGF2 positively regulates osteoclastogenesis via stimulating the ERK-CREB pathway. These findings establish the importance of FGF2 in bone homeostasis, hinting the potential use of FGF2/ERK/CREB specific inhibitors to fight against bone-related disorders, such as osteoporosis.

GSK 650394 Inhibits Osteoclasts Differentiation and Prevents Bone Loss via Promoting the Activities of Antioxidant Enzymes In Vitro and In Vivo

Osteoporosis (OP) is one of the most common bone disorders among the elderly, characterized by abnormally elevated bone resorption caused by formation and activation of osteoblast (OC). Excessive reactive oxygen species (ROS) accumulation might contribute to the formation process of OC as an essential role. Although accumulated advanced treatment target on OP have been proposed in recent years, clinical outcomes remain unexcellence attributed to severe side effects. The purpose of present study was to explore the underlying mechanisms of GSK 650394 (GSK) on inhibiting formation and activation of OC and bone resorption in vitro and in vivo. GSK could inhibit receptor activator of nuclear-κB ligand (RANKL-)-mediated Oc formation via suppressing the activation of NF-κB and MAPK signaling pathways, regulating intracellular redox status, and downregulate the expression of nuclear factor of activated T cells c1 (NFATc1). In addition, quantitative RT-PCR results show that GSK could suppress the expression of OC marker gene and antioxidant enzyme genes. Consistent with in vitro cellular results, GSK treatment improved bone density in the mouse with ovariectomized-induced bone loss according to the results of CT parameters, HE staining, and Trap staining. Furthermore, GSK treatment could enhance the capacity of antioxidant enzymes in vivo. In conclusion, this study suggested that GSK could suppress the activation of osteoclasts and therefore maybe a potential therapeutic reagent for osteoclast activation-related osteoporosis.

Antiosteoporosis and bone protective effect of nimbolide in steroid-induced osteoporosis rats

BACKGROUND

Osteoporosis is a metabolic, hereditary, progressive disease characterized by unusual bone production across the skeleton and a loss the bone tissue microstructure and mass. In this experimental study, we scrutinized the antiosteoporosis effect of nimbolide against glucocorticoid (GCs) induced osteoporosis in rats.

METHODS

Swiss albino female rats were employed for the current experiment study and the rats were divided into different groups. Dexamethasone (0.1 mg/kg/day) was used for induction the osteoporosis and the rats were received the different doses of nimbolide (2.5, 5, and 7.5 mg/kg) for the estimation of bone protective effects. The body weight was estimated (initially and finally). Hormones, bone metabolic markers, bone turnover markers, bone structure, biomechanical, histomorphometric dynamic, biochemical markers, and histomorphometric static parameters were analyzed.

RESULTS

The body weight of GCs group rats considerably suppressed and nimbolide treatment remarkably improved the body weight. Nimbolide treated group exhibited the enhancement of bone metabolic, bone structure markers, and histomophometric dynamic markers, which was suppressed during the GCs-induced osteoporosis. GCs-induced osteoporosis rats exhibited the enhancement of procollagen type 1 C-terminal propeptide (P1CP), carboxy-terminal crosslinked telopeptide of type 1 collagen (CTX-1), Dickkopf-1 (DKK1), tartrate-resistant acid phosphatase 5b (TRACP 5b), and suppressed the level of bone alkaline phosphatase (BAP), which was reversed by the nimbolide treatment. Nimbolide treatment remarkably improved the level of estradiol and suppressed the level of parathyroid hormone (PTH), which was altered during the osteoporosis. Nimbolide treatment significantly (p < 0.001) improved the level of calcium, magnesium, and phosphorus in the serum and bone tissue. Nimbolide treatment also altered the level of bone metabolic markers and suppressed the level of inflammatory cytokines.

CONCLUSION

Based on the findings, we may conclude that nimbolide has antiosteoporosis properties via balancing the bone mass and improving vitamin and hormone levels.

Moringa oleifera leaf extract induces osteogenic-like differentiation of human osteosarcoma SaOS2 cells

Introduction

Moringa oleifera is known as a ‘natural nutrition of the tropics’ because it provides vital nutritional supplements and a variety of pharmacological benefits. The focus of this study was to elucidate the dose dependent effects of Moringa oleifera leaf (MOL) extract on the growth of the human osteoblast-like osteosarcoma SaOS-2 cell line and primary osteoblast cells.

Methods

Trypan blue & tetrazolium assay, intracellular ROS generation, chromatin condensation, cell cycle analysis, alkaline phosphatase (ALP), mineralization, and osteogenic gene expression were tested on both treated and untreated osteosarcoma SaOS-2 cells.

Results

As revealed by cell viability assay, growth activity was observed at concentrations 25 and 50 μg/mL of MOL extract, whereas 100 and 200 μg/mL doses decreased the proliferation activity, resulting in ROS production and chromatin condensation. Cell cycle study revealed that MOL extract at 50 and 100 μg/mL concentrations arrested the cells in the G2/M phase. Low doses increased the ALP levels, mineralization, and expression of the bone morphogenetic protein 2 (BMP2) and runt-related transcription factor 2 (Runx2) genes in osteoblast-like SaOS-2 cells, however, high doses inhibited the proliferation properties of MOL extract. Through AutoDock Vina and iGEMDOCK 2.1, the interaction of active components of MOL, such as β-sitosterol, quercetin and kaempferol, with BMP2 and Runx2 proteins revealed a reasonable binding affinity. Moreover, these components did not show any Lipinski's rule of five violation and showed predictable pharmacokinetic properties.

Conclusion

The results of the biphasic dose-response of MOL extract on the growth activity of osteoblast-like SaOS-2 cells and in silico binding interface, may provide a therapeutic and/or preventive implication in prospective drug development.

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Low doses of Moringa oleifera leaf (MOL) extract increased the cell viability of SaOS-2 cells and primary osteoblasts.

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High doses decreased the growth, resulting in ROS production and chromatin condensation and cell cycle arrest.

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Small doses increased the ALP levels, mineralization, and BMP2 and Runx2 genes expression, and vice versa.

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In silico analysis showed good binding interaction of active components of MOL with BMP2 and Runx2 proteins.

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The biphasic dose-response of MOL and in silico analysis may provide an implication for prospective drug development.

Cost-effectiveness studies of vertebral augmentation for osteoporotic vertebral fractures: a systematic review

BACKGROUND CONTEXT

Osteoporotic vertebral fractures (OVF) dramatically increase with age and are serious life altering adverse events for seniors resulting in increased rates of institutionalization, morbidity and mortality. Given the expanding population of the elderly and increasing prevalence of OVFs, cost-effective treatment strategies need to be considered. Percutaneous vertebral augmentation (VA) procedures such as vertebroplasty (VP) or balloon kyphoplasty (BK) are increasingly employed to treat painful vertebral fractures not responding to conservative management (CM) of bedrest and analgesia. Both VA procedures have been shown to be effective treatments for OVFs in multiple systematic reviews of randomized controlled trials. In this systematic review, analytical strategies, designs and results were compared for health economic studies evaluating cost-effectiveness of VA procedures, VP or BK for OVFs. Furthermore, assessments of quality (risk of bias) were conducted for the systematic review and the individual studies with peer-reviewed checklists recommended for cost-effectiveness studies.

PURPOSE

To provide an up-to-date systematic review of peer-reviewed studies evaluating cost-effectiveness of VA procedures, VP or KP for OVFs to support treatment and health care funding decisions.

STUDY DESIGN

This study is a systematic literature review and structured narrative synthesis.

STUDY SAMPLE

Peer reviewed health economic studies reporting cost-effectiveness for VA procedures, VP or BK for OVFs OUTCOME MEASURES: The following information extracted from the studies included: report country and year, study design, comparators, population, perspective, health valuations, costing sources and cost-effectiveness measures. For economic studies involving modeling, information was also extracted for model type, time horizon, key model drivers, and handling of uncertainty. Incremental cost-effectiveness ratio (ICER), the ratio of differences between comparator treatment groups in costs and health benefits, was considered the main cost-effectiveness measure.

METHODS

A systematic review was conducted of MEDLINE, EMBASE, CINAHL, ECONLIT, Cochrane Library and DARE databases up to the review date May 2021. Studies were reviewed for those reporting cost-effectiveness analyses on VA procedures including VP or BK for OVFs. Studies including only costs, abstracts, editorials, methodologies and reviews were not included. The selection of articles was reported in line with PRISMA guidance. A descriptive framework was developed to classify types of cost-effectiveness studies based on methodological differences and a structured narrative synthesis was used to summarize studies. Quality assessments were made with British Medical Journal checklist for individual cost-effectiveness studies and the CiCERO checklist for systematic reviews of cost-effectiveness studies.

RESULTS

In this systematic review, 520 references were identified through database searching and 501 were excluded as ineligible by titles and abstract based on prior eligibility criteria. From full-text reviews of 19 reports, ten were identified as eligible for the systematic review evaluating cost-effectiveness of VA procedures for OVFs. All references were published between 2008 and 2020. The ten cost-effectiveness studies, three for VP, three for BK and four for both VP and BK, all involved CM for OVFs as a treatment comparator. The studies involved different methods of economic analysis, modeling assumptions, cost and health valuations conducted in different health care setting over different time periods. A framework for the review outlines key features of cost-effectiveness study designs consisting of unmatched, matched, or randomized controls involving cost-effectiveness or cost-utility) analyses. Both VP and BK were cost-effective alternatives to CM for OVFs with earlier health gains and significantly shorter hospital stays. Cost-effectiveness estimates, ICERs, remained relatively stable and within willingness-to-pay thresholds under a range of sensitivity analyses. Comparisons between VP and BK were variable depending on modeling assumptions, but generally the procedures had similar health benefit gains with VP having lower acute procedural costs.

CONCLUSIONS

Both VP and BK, have been shown to be cost-effective alternatives to CM for osteoporotic vertebral fractures in diverse cost-effectiveness studies conducted in multiple health care settings. Trial-based cost-utility contributed the strongest evidence supporting cost-effectiveness determination for VP and BK for OVFs.

The Impact of Various Anti-Osteoporosis Drugs on All-Cause Mortality After Hip Fractures: A Nationwide Population Study

Anti-osteoporosis treatment following hip fractures may reduce the overall mortality rate. However, the effects of different drugs on mortality is still unclear. This population-based cohort study aimed to identify the degree of reduced mortality after various anti-osteoporosis regimens following hip fracture surgery. We conducted this cohort study to identify patients with newly diagnosed osteoporosis and hip fractures from 2009 to 2017 using the Taiwan National Health Insurance Research Database (NHIRD). The subsequent use of anti-osteoporosis medication following hip fracture surgery was collected and analyzed. National death registration records were retrieved to determine mortality. A total of 45,226 new cases of osteoporotic hip fracture were identified. Compared with patients who did not receive further treatment, patients who had ever used oral bisphosphonates (alendronate and risedronate, hazard ratio [HR] 0.81; 95% confidence interval [CI], 0.78-0.84), ibandronate (HR 0.76; 95% CI, 0.67-0.86), zoledronic acid (HR 0.70; 95% CI, 0.64-0.76), and denosumab (HR 0.64; 95% CI, 0.60-0.68) showed lower all-cause mortality rates. Patients treated with bisphosphonates had a lower mortality risk than those treated with selective estrogen receptor modulators (HR 0.81; 95% CI, 0.75-0.87). Patients treated with zoledronic acid showed a lower mortality risk than those treated with oral bisphosphonates (HR 0.89; 95% CI, 0.82-0.97). However, patients receiving denosumab and zoledronic acid did not show a significant difference in mortality (HR 0.94; 95% CI, 0.85-1.03). Different anti-osteoporosis treatments for postsurgical patients were associated with different levels of decline in mortality. Generally, longer durations of drug use were associated with lower mortality. © 2022 American Society for Bone and Mineral Research (ASBMR).

Fracture risk in breast cancer: does obesity have an effect? A Scoping Review

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Obesity may be associated with increased fracture risk in females with breast cancer.

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Exercise appears to have an inverse association with the risk for fracture.

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At the time of publication, there is no literature that examines the effects of obesity on fracture risk in breast cancer bone metastasis.

Background

Objectives

Design

Data synthesis and results

Conclusions

Priming with a Combination of FGF2 and HGF Restores the Impaired Osteogenic Differentiation of Adipose-Derived Stem Cells

Classical aging-associated diseases include osteoporosis, diabetes, hypertension, and arthritis. Osteoporosis causes the bone to become brittle, increasing fracture risk. Among the various treatments for fractures, stem cell transplantation is currently in the spotlight. Poor paracrine/differentiation capacity, owing to donor age or clinical history, limits efficacy. Lower levels of fibroblast growth factor 2 (FGF2) and hepatocyte growth factor (HGF) are involved in cell repopulation, angiogenesis, and bone formation in the elderly ADSCs (ADSC-E) than in the young ADSCs (ADSC-Y). Here, we study the effect of FGF2/HGF priming on the osteogenic potential of ADSC-E, determined by calcium deposition in vitro and ectopic bone formation in vivo. Age-induced FGF2/HGF deficiency was confirmed in ADSCs, and their supplementation enhanced the osteogenic differentiation ability of ADSC-E. Priming with FGF2/HGF caused an early shift of expression of osteogenic markers, including Runt-related transcription factor 2 (Runx-2), osterix, and alkaline phosphatase (ALP) during osteogenic differentiation. FGF2/HGF priming also created an environment favorable to osteogenesis by facilitating the secretion of bone morphogenetic protein 2 (BMP-2) and vascular endothelial growth factor (VEGF). Bone tissue of ADSC-E origin was observed in mice transplanted with FGF/HGF-primed ADSC-E. Collectively, FGF2/HGF priming could enhance the bone-forming capacity in ADSC-E. Therefore, growth factor-mediated cellular priming can enhance ADSC differentiation in bone diseases and thus contributes to the increased efficacy in vivo.

16S rDNA analysis of osteoporotic rats treated with osteoking

Introduction. Osteoporosis (OP) is characterized by microstructural degeneration of bone tissue, low bone mass, bone fragility and even brittle fracture (osteoporotic fracture, OPF). OP and OPF are common and there are many disadvantages to the current medications for OP/OPF. Osteoking is a traditional Chinese medicine (TCM) originating from the Yi nationality (Yunnan, China) that has been used to treat bone diseases for decades.Hypothesis/Gap Statement. This study will reveal the changes in the intestinal microbiota of OP rats after 70 days of osteoking treatment.Method. With duplication of sham and OP rats, eight groups were established, with six rats in each group. The intestinal microbiotas were analysed by 16S rDNA sequencing.Results. The results showed that osteoking changed the intestinal microbiota of sham rats and OP rats. The mechanism by which osteoking improves OP is related to the functions of the intestinal microbiota. After 70 days of treatment with osteoking, the contents of Pseudonocardia, Pedomicrobium, Variovorax, Niastella and Actinosynnema were decreased in OP rats. The functions of the above intestinal microbiota related to iron metabolism affected calcifediol and 25(OH)D, and measuring these bone metabolic indicators is required for further study.Conclusion. Osteoking changes the intestinal microbiota to improve OP, and further study which reveals these intestinal microbiota and mechanism is needed.

Stochastic failure analysis of proximal femur using an isogeometric analysis based nonlocal gradient-enhanced damage model

BACKGROUND AND OBJECTIVE

Medical imaging-based finite element methods are more accurate tools for fracture risk prediction than the traditional aBMD based methods. However, these methods have drawbacks like geometric errors, high computational cost, mesh-dependent results, etc. In this article, the authors have proposed an isogeometric analysis-based nonlocal gradient-enhanced damage model to overcome some of these issues. Moreover, there are uncertainties in the values of input parameters for such analysis due to various measurement errors. Hence, stochastic analysis is performed to quantify the effect of these parametric uncertainties on the fracture behavior of the proximal femur.

METHODS

Computed Tomography images of a patient are used to create a 2D proximal femur model with a heterogeneous description of material properties. A numerical model based on gradient-enhanced nonlocal continuum damage mechanics is used for fracture analysis of proximal femur to overcome the issues related to mesh dependency in traditional continuum damage mechanics models. Further, a multipatch isogeometric solver is developed to solve the governing equations. Monte Carlo simulations are used to understand the effect of parametric uncertainties on the fracture behavior of the proximal femur.

RESULTS

The developed numerical framework is used to solve the fracture problem of proximal femur under single leg stance loading conditions. The obtained results are validated by comparing the load-displacement response and the crack path with that given in the literature. Stochastic analysis is performed by considering a ±5% variation in the elastic modulus, damage initiation strain, and the neck-shaft angle values.

CONCLUSION

The proposed numerical framework can correctly predict the damage initiation and propagation in a proximal femur. The results reveal that the heterogeneous nature of material properties of bone plays a significant role in determining the fracture characteristics of the proximal femur. Further, the results of the stochastic analysis reveal that the parametric uncertainties in the neck-shaft angle have a much more significant influence on the results of the analysis than the parametric uncertainties in the elastic modulus and damage initiation strain.

Is It Possible to Predict the Length of Stay of Patients Undergoing Hip-Replacement Surgery?

The proximal fracture of the femur and hip is the most common reason for hospitalization in orthopedic departments. In Italy, 115,989 hip-replacement surgeries were performed in 2019, showing the economic relevance of studying this type of procedure. This study analyzed the data relating to patients who underwent hip-replacement surgery in the years 2010-2020 at the "San Giovanni di Dio e Ruggi d'Aragona" University Hospital of Salerno. The multiple linear regression (MLR) model and regression and classification algorithms were implemented in order to predict the total length of stay (LOS). Lastly, using a statistical analysis, the impact of COVID-19 was evaluated. The results obtained from the regression analysis showed that the best model was MLR, with an R² value of 0.616, compared with XGBoost, Gradient-Boosted Tree, and Random Forest, with R² values of 0.552, 0.543, and 0.448, respectively. The t-test showed that the variables that most influenced the LOS, with the exception of pre-operative LOS, were gender, age, anemia, fracture/dislocation, and urinary disorders. Among the classification algorithms, the best result was obtained with Random Forest, with a sensitivity of the longest LOS of over 89%. In terms of the overall accuracy, Random Forest and Gradient-Boosted Tree achieved a value of 71.76% and an error of 28.24%, followed by Decision Tree, with an accuracy of 71.13% and an error of 28.87%, and, finally, Support Vector Machine, with an accuracy of 65.06% and an error of 34.94%. A significant difference in cardiovascular disease, fracture/dislocation, and post-operative LOS variables was shown by the chi-squared test and Mann-Whitney test in the comparison between 2019 (before COVID-19) and 2020 (in full pandemic emergency conditions).

Auraptene ameliorates osteoporosis by inhibiting RANKL/NFATc1 pathway-mediated bone resorption based on network pharmacology and experimental evaluation

AIMS

The association of auraptene (AUR), a 7-geranyloxycoumarin, on osteoporosis and its potential pathway was predicted by network pharmacology and confirmed in experimental osteoporotic mice.

METHODS

The network of AUR was constructed and a potential pathway predicted by Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway and Gene Ontology (GO) terms enrichment. Female ovariectomized (OVX) Institute of Cancer Research mice were intraperitoneally injected with 0.01, 0.1, and 1 mM AUR for four weeks. The bone mineral density (BMD) level was measured by dual-energy X-ray absorptiometry. The bone microstructure was determined by histomorphological changes in the femora. In addition, biochemical analysis of the serum and assessment of the messenger RNA (mRNA) levels of osteoclastic markers were performed.

RESULTS

In total, 65.93% of the genes of the AUR network matched with osteoporosis-related genes. Osteoclast differentiation was predicted to be a potential pathway of AUR in osteoporosis. Based on the network pharmacology, the BMD and bone mineral content levels were significantly (p < 0.05) increased in the whole body, femur, tibia, and lumbar spine by AUR. AUR normalized the bone microstructure and the serum alkaline phosphatase (ALP), bone-specific alkaline phosphatase (bALP), osteocalcin, and calcium in comparison with the OVX group. In addition, AUR treatment reduced TRAP-positive osteoclasts and receptor activator of nuclear factor kappa-B ligand (RANKL)⁺nuclear factor of activated T cells 1 (NFATc1)⁺ expression in the femoral body. Moreover, the expressions of initiators for osteoclastic resorption and bone matrix degradation were significantly (p < 0.05) regulated by AUR in the lumbar spine of the osteoporotic mice.

CONCLUSION

AUR ameliorated bone loss by downregulating the RANKL/NFATc1 pathway, resulting in improvement of osteoporosis. In conclusion, AUR might be an ameliorative cure that alleviates bone loss in osteoporosis via inhibition of osteoclastic activity. Cite this article: Bone Joint Res 2022;11(5):304-316.

Global incidence, prevalence, and disability of vertebral fractures: a systematic analysis of the global burden of disease study 2019

BACKGROUND CONTEXT

In the context of the population growing and aging worldwide, the epidemiology, and burden of vertebral fracture have not been comprehensively analyzed.

PURPOSE

To delineate the global number and rate of incidence, prevalence and burden of vertebral fracture in 2019, and the temporal trends from 1990 to 2019 by location, age, sex, and the socio-demographic index (SDI).

STUDY DESIGN/SETTING

A cross-sectional study using data from the Global Burden of Disease Study 2019 (GBD study 2019).

PATIENT SAMPLE

Patients with vertebral fracture documented in medical records or registrations and included in the GBD study 2019 from different countries worldwide.

OUTCOME MEASURES

Age standardized incidence rate (ASIR), age standardized prevalence rate (ASPR), and age standardized years lived with disability (YLDs).

METHODS

The GBD study 2019 was used to obtain data for this analysis. The incidence, prevalence and disability were analyzed by location, year, sex, age, and SDI. DisMod-MR 2.1, a Bayesian meta-regression tool, was used to produce the estimates for each value after adjustment for age, sex, and other variables. Estimated annual percentage change (EAPC) was calculated to represent the temporal trends from 1990 to 2019. Spearman's rank order correlation was used to determine the correlation between SDI and the incidence and burden of vertebral fracture. This work was supported by the Key Research and Development Program of Hubei Province of China (No. 2020BCB049), and no conflicts of interest-associated biases existed in this study.

RESULTS

Globally, there were 8.6 million (95% uncertainty interval [UI], 6,6-11,3 million) incident cases, 5.3 million (95% UI, 4.6-6.2 million) prevalent cases, and 0.55 million (95% UI, 0.37-0.77 million) YLDs of vertebral fracture. Compared with 1990, the number of incident cases and YLDs in 2019 increased by 38% (95% UI, 23%-48%) and 75% (95% UI, 65%-85%), respectively, while the ASIR (EAPC, -0.28; 95% CI, -0.41 to -0.14), ASPR (EAPC, -0.12; 95% CI, -0.22 to -0.02) and age standardized YLD rate (ASYR) (EAPC, -0.13; 95% CI, -0.23 to -0.04) decreased during this period. High ASIR, ASPR and ASYR were commonly seen in high-SDI countries, such as high-income North America, Australia, Central and Eastern Europe. In the country level, positive correlations were observed between SDI and ASIR (rho, 0.596; p<.001) and ASYR (rho, 0.413; p<.001). Males had higher ASIR and ASYR worldwide in each year from 1990 to 2019. However, the incidence, and YLD rates in females surpassed that in males after 65 years of age. Increasing trends were observed for both incidence and YLD rates with age. Falls were the leading cause for vertebral fracture across all ages.

CONCLUSIONS

The past thirty years have seen increasing numbers but decreasing rates of global incidence, prevalence, and disability of vertebral fractures, resulting from the growing population worldwide. With population aging, efforts are still in urgent need to address vertebral fracture related health outcomes.

Transcription Factor KLF7 Promotes Osteoclast Differentiation by Suppressing HO-1

Background: Osteoporosis is a common orthopedic disease with high prevalence in patients older than 50 years. Osteoporosis is often detected only after the fracture and is hard to treat. Therefore, it is of great significance to explore the molecular mechanism of the occurrence of osteoporosis.

Methods: The expression of Heme oxygenase-1 (HO-1) in people with different bone mineral density (BMD) was analyzed based on public databases. GenHacncer and JASPAR databases were adopted to search and verify the upstream transcription factor of HO-1. qRT-PCR, western blot and tartrate-resistant acid phosphatase assays were performed to explore the impact of HO-1 and Kruppel-like factor 7 (KLF7) on osteoclast differentiation. Chromatin immunoprecipitation (ChIP) assay confirmed the binding relationship between KLF7 and HO-1. Finally, Hemin, the agonist of HO-1, was applied in rescue assays, thereby verifying the mechanism of KLF7 modulating osteoclast differentiation by HO-1.

Results: Bioinformatics analysis revealed that HO-1 was highly-expressed while KLF7 lowly-expressed in people with high BMD. Besides, a potential binding site of KLF7 was found on the promoter region of HO-1. ChIP assay further manifested the targeting relationship between HO-1 and KLF7. Western blot and TRAP staining unveiled that osteoclast differentiation was suppressed by HO-1, while facilitated by KLF7. Rescue experiments indicated that over-expressed HO-1 could reverse of the promoting effect of KLF7 on osteoclast differentiation.

Conclusion: The study confirmed that osteoclast differentiation was promoted by KLF7 constraining HO-1, thereby facilitating osteoporosis. The cognation of the pathogenesis of osteoporosis was further enriched. New treatment could be developed on this basis.