Epidemiology of fracture risk in the Women's Health Initiative

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

STUDY DESIGN

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

PURPOSE

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

OVERVIEW OF LITERATURE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The development, incidence and treatment trends of trochanteric fractures in Germany: a cohort study

BACKGROUND

Hip fractures are a major public health problem worldwide and can lead to disability, increased mortality, and reduced quality of life. We aim to provide a nationwide epidemiological analysis of trochanteric and subtrochanteric fractures and their respective surgical treatments.

METHODS

Data were retrieved from the national database of the German Department of the Interior. ICD-10-GM and OPS data from the period of 2006 to 2020 were analysed and all patients with trochanteric and subtrochanteric fractures as their main diagnosis, who were treated in a German hospital, were included. Patients were grouped by age and gender and linear regression was performed where suitable to calculate statistically significant correlations between variables and incidences.

RESULTS

985,104 pertrochanteric fractures and 178,810 subtrochanteric fractures were reported during the analysed period. We calculated a mean incidence of 80.08 ± 6.34 for pertrochanteric and 14.53 ± 1.50 for subtrochanteric fractures per million inhabitants. In both fracture types, a distinct dependence of incidence on age can be determined. Incidence rates equally rise in both sexes through the age groups with an increase of about 288-fold from those under the age of 60 to those over the age of 90 in pertrochanteric fractures, and about 123-fold in subtrochanteric fractures. Intramedullary nailing was the most common kind of treatment for both fracture types with augmentative cerclages on the rise throughout the whole period. Plate and dynamic compression screws were decreasing in frequency over the analysed period in both fractures.

CONCLUSIONS

We provided incidence data on per- and subtrochanteric fractures and their treatment. We calculated an economic impact of approximately 1.563 billion € per year in Germany. With regards to recent literature on costs of treatment and our findings regarding the implementation and utilization of different treatment methods, we conclude that the reinforcement of nationwide prevention programs is a relevant step in lessening the economic burden. We welcome the increased utilisation of intramedullary nailing as many studies show beneficiary outcomes and cost effectiveness in most of the included fracture types.

Associations Between Inflammatory Mediators and Bone Outcomes in Postmenopausal Women: A Cross-Sectional Analysis of Baseline Data from the Prune Study

Purpose

Hypoestrogenism triggers increased production of inflammatory mediators, which contribute to bone loss during postmenopausal osteoporosis. This study aimed to investigate the association between circulating inflammatory markers and bone outcomes in postmenopausal women.

Materials and methods

We conducted a cross-sectional, secondary analysis of baseline data from participants who completed a 12-month randomized controlled trial, The Prune Study (NCT02822378), which included healthy postmenopausal women (n=183, 55-75 years old) with bone mineral density (BMD) T-score between 0.0 and -3.0 at any site. BMD was measured using dual-energy X-ray absorptiometry, and bone geometry and strength were measured using peripheral quantitative computed tomography. Blood was collected at baseline to measure (1) serum biomarkers of bone turnover, including procollagen type 1 N-terminal propeptide (P1NP) and C-terminal telopeptide and (2) inflammatory markers, including serum high-sensitivity C-reactive protein (hs-CRP) and plasma pro-inflammatory cytokines, tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, and monocyte chemoattractant protein (MCP)-1, using enzyme-linked immunosorbent assay. The associations between bone and inflammatory outcomes at baseline were analyzed using correlation and regression analyses.

Results

Serum hs-CRP negatively correlated with P1NP (r=-0.197, p=0.042). Plasma IL-1β, IL-6, IL-8, and TNF-α negatively correlated with trabecular bone score at the lumbar spine (all p<0.05). In normal-weight women, plasma IL-1β, IL-6, and IL-8 negatively correlated (p<0.05) with trabecular and cortical bone area, content, and density at various sites in the tibia and radius. Serum hs-CRP positively predicted lumbar spine BMD (β=0.078, p=0.028). Plasma IL-6 negatively predicted BMD at the total body (β=-0.131, p=0.027) and lumbar spine (β=-0.151, p=0.036), whereas plasma TNF-α negatively predicted total hip BMD (β=-0.114, p=0.028).

Conclusion

At baseline, inflammatory markers were inversely associated with various estimates of bone density, geometry, and strength in postmenopausal women. These findings suggest that inflammatory markers may be an important mediator for postmenopausal bone loss.

Racial and Ethnic Disparities in Bone Health and Outcomes in the United States

Osteoporosis is a bone disease classified by deterioration of bone microarchitecture and decreased bone strength, thereby increasing subsequent risk of fracture. In the United States, approximately 54 million adults aged 50 years and older have osteoporosis or are at risk due to low bone mass. Osteoporosis has long been viewed as a chronic health condition affecting primarily non-Hispanic white (NHW) women; however, emerging evidence indicates racial and ethnic disparities in bone outcomes and osteoporosis management. The primary objective of this review is to describe disparities in bone mineral density (BMD), prevalence of osteoporosis and fracture, as well as in screening and treatment of osteoporosis among non-Hispanic black (NHB), Hispanic, and Asian adults compared with NHW adults living on the US mainland. The following areas were reviewed: BMD, osteoporosis prevalence, fracture prevalence and incidence, postfracture outcomes, DXA screening, and osteoporosis treatments. Although there are limited studies on bone and fracture outcomes within Asian and Hispanic populations, findings suggest that there are differences in bone outcomes across NHW, NHB, Asian, and Hispanic populations. Further, NHB, Asian, and Hispanic populations may experience suboptimal osteoporosis management and postfracture care, although additional population-based studies are needed. There is also evidence that variation in BMD and osteoporosis exists within major racial and ethnic groups, highlighting the need for research in individual groups by origin or background. Although there is a clear need to prioritize future quantitative and qualitative research in these populations, initial strategies for addressing bone health disparities are discussed. © 2021 American Society for Bone and Mineral Research (ASBMR).

The association of objectively ascertained sibling fracture history with major osteoporotic fractures: a population-based cohort study

We investigated the association of objectively ascertained sibling fracture history with major osteoporotic fracture (hip, forearm, humerus, or clinical spine) risk in a population-based cohort using administrative databases. Sibling fracture history is associated with increased major osteoporotic fracture risk, which has implications for fracture risk prediction.

INTRODUCTION

We aimed to determine whether objectively ascertained sibling fracture history is associated with major osteoporotic fracture (MOF; hip, forearm, humerus, or clinical spine) risk.

METHODS

This retrospective cohort study used administrative databases from the province of Manitoba, Canada, which has a universal healthcare system. The cohort included men and women 40+ years between 1997 and 2015 with linkage to at least one sibling. The exposure was sibling MOF diagnosis occurring after age 40 years and prior to the outcome. The outcome was incident MOF identified in hospital and physician records using established case definitions. A multivariable Cox proportional hazards regression model was used to estimate the risk of MOF after adjustment for known fracture risk factors.

RESULTS

The cohort included 217,527 individuals; 91.9% were linked to full siblings (siblings having the same father and mother) and 49.0% were females. By the end of the study period, 6255 (2.9%) of the siblings had a MOF. During a median follow-up of 11 years (IQR 5-15), 5235 (2.4%) incident MOF were identified in the study cohort, including 234 hip fractures. Sibling MOF history was associated with an increased risk of MOF (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.44-1.92). The risk was elevated in both men (HR 1.57, 95% CI 1.24-1.98) and women (HR 1.74, 95% CI 1.45-2.08). The highest risk was associated with a sibling diagnosis of forearm fracture (HR 1.81, 95% CI 1.53-2.15).

CONCLUSION

Sibling fracture history is associated with increased MOF risk and should be considered as a candidate risk factor for improving fracture risk prediction.

Longitudinal changes over three years in sex steroid hormone levels in women aged 70 years and over

OBJECTIVE

Sex steroid levels in women vary with increasing age from the age of 70 years (70+). Whether this reflects change within individuals with age or a survival advantage is not known. This study aimed to determine the stability of circulating sex steroids and SHBG over time in individual women aged 70+.

DESIGN

A prospective cohort study.

PARTICIPANTS

400 women, aged 70+ not using any sex steroid, anti-androgen/oestrogen or glucocorticoid therapy.

MAIN OUTCOME MEASUREMENTS

Sex steroid concentrations, measured by liquid chromatography-tandem mass spectrometry and sex hormone-binding globulin (SHBG) by immunoassay, in paired blood samples drawn 3 years apart and analysed together.

RESULTS

400 women, median (IQR) age 78.0 (8.6) years, were included in the analysis. Mean testosterone concentrations were statistically significantly higher in follow-up samples compared with baseline. The change was modest (mean change 31 pmol/L, 95% confidence interval (CI) 2.4-59.8; p = .034), and an increase was not observed in all women. There was a statistically significant decline in mean body mass index (mean change -0.4 kg/m² , 95% CI 0.6 to -0.3; p < .001) and a significant increase in the mean serum SHBG concentration (mean change 4.0 nmol/L, 95% CI 2.7-5.4; p < .001). The change observed in testosterone was not explained by the observed change in SHBG. There was no significant change in the mean oestrone or dehydroepiandrosterone concentration.

CONCLUSIONS

Testosterone concentrations in women aged 70+ were more likely to increase than decrease. Whether increasing testosterone concentrations in older women confer a survival advantage needs investigation.

Retrospective Analysis of the Effects of Non-Compliance with Denosumab on Changes in Bone Mineral Density During the COVID-19 Pandemic

PURPOSE

Although denosumab is a safe and effective treatment for osteoporosis in various clinical trials, few studies have investigated its efficacy in specific clinical situations. The effect of non-compliance with the standard six-month dosing regimen for denosumab on bone mineral density (BMD) was assessed in a retrospective study of patients prescribed denosumab during the COVID-19 pandemic.

PATIENTS AND METHODS

Between February 2019 and September 2020, 638 patient records were reviewed, with 236 patients meeting the eligibility criteria. Patients were divided into three groups: those who received denosumab injections between five and seven months after their initial subcutaneous injection, those who received denosumab injections between seven and nine months after their initial subcutaneous injection, and those who received denosumab injections more than nine months after their initial subcutaneous injection. A multivariate regression study was conducted to compare the BMD shift (at least one year apart) before and after two denosumab injections between the three pre-specified groups in both the lumbar spine (LS) and the femoral neck (FN).

RESULTS

The difference between LS BMD indicates that there is a statistical difference between subjects who received denosumab injections between 5 and 7 months (near-standard dosing interval) and more than 9 months (P=0.03), but not in FN BMD, and no clinically significant association was identified.

CONCLUSION

The results of this study show that in special clinical situations, such as the COVID-19 pandemic, clinicians may have some flexibility to prescribe denosumab, but the interval between injections should not exceed 9 months.

The impact of nonstandard hip rotation on densitometric results of hip regions and potential misclassification of diagnosis

The present study is intended to investigate the degree to which insufficient internal rotation could impact the densitometric results and change the diagnosis. A significant difference was found between the results in nonstandard compared with standard rotation and an increase in the BMD and T- and Z-scores from nonstandard to standard rotation. Likewise, a change in diagnosis was observed in a significant proportion of patients.

PURPOSE

To investigate the impact of nonstandard rotation of hip on the densitometric results of femoral neck and total femur region as well as the amount of change in diagnosis (i.e., misclassification of diagnosis) based on hip region.

METHODS

Ninety-seven patients (88 females and 9 males) were included in the study. After receiving informed consent, each subject underwent a densitometric scanning in two modes, one with standard rotation of the leg and the other with nonstandard rotation (i.e., the leg in relaxed position without applying the positioner to strap the foot to) of the same leg. All data were analyzed using the auto-analysis option of the HOLOGIC® software. Bone densitometric results, T- and Z-scores, rate of change in diagnosis, and also the agreement between the diagnoses in the two modes are calculated and compared by using a paired-sample t test and cross-tabulation.

RESULTS

The mean age of 97 patients was 56.91 ± 11.70 years. A significant difference was found in the BMDs, T-scores, and Z-scores of the neck and total femur regions of interest in standard and nonstandard rotations. We found an increase in the BMD of the femoral neck and total femur of 0.020 and 0.010 g/cm2, respectively, from standard to nonstandard leg rotation and that this, in turn, led to a 0.4 and a 0.13 increases in T-scores of the neck and total femur, respectively, from standard to nonstandard rotation. In the diagnosis based on femoral neck only, the diagnosis changed in 17 (17.5%) patients, i.e., 12 (12.4%) from osteopenia to normal, 3 (3.1%) from osteoporosis to osteopenia, and 2 (2.0%) from below the expected range for age to within the expected range for age. There was only a change of one level in diagnosis.

DISCUSSION AND CONCLUSIONS

According to the results, the changes in the BMD and T- and Z-scores can be interpreted as underdiagnosis or, in simple terms, not finding the disease or underestimating the level of disease. Therefore, proper rotation of the leg is an important factor during densitometry. Any deviation from standard rotation changes the BMD of those regions, and thereby the T- and Z-scores accordingly, and thus the diagnosis.

Preoperative Assessment of Bone Quality in Spine Deformity Surgery: Correlation With Clinical Practice and Published Recommendations

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The goals of this study were to (A) evaluate preoperative bone quality assessment and intervention practice over time and (B) review the current evidence for bone evaluation in spine fusion surgery.

SUMMARY OF BACKGROUND DATA

Deformity spine surgery has demonstrated improved quality of life in patients; however, its cost has made it controversial. If preoperative bone quality can be optimized then potentially these treatments could be more durable; however, at present, no clinical practice guidelines have been published by professional spine surgical organizations.

METHODS

A retrospective cohort review was performed on patients who underwent a minimum five-level primary or revision fusion. Preoperative bone quality metrics were evaluated over time from 2012 to 2017 to find potential trends. Subgroup analysis was conducted based on age, sex, preoperative diagnosis, and spine fusion region.

RESULTS

Patient characteristics including preoperative rates of pseudarthrosis and junctional failure did not change. An increasing trend of physician bone health documentation was noted (P = 0.045) but changes in other metrics were not significant. A sex bias favored females who had higher rates of preoperative DXA studies (P = 0.001), Vitamin D 25-OH serum labs (P = 0.005), Vitamin D supplementation (P = 0.022), calcium supplementation (P < 0.001), antiresorptive therapy (P = 0.016), and surgeon clinical documentation of bone health (P = 0.008) compared with men.

CONCLUSION

Our spine surgeons have increased documentation of bone health discussions but this has not affected bone quality interventions. A discrepancy exists favoring females over males in nearly all preoperative bone quality assessment metrics. Preoperative vitamin D level and BMD assessment should be considered in patients undergoing long fusion constructs; however, the data for bone anabolic and resorptive agents have less support. Clinical practice guidelines on preoperative bone quality assessment spine patients should be defined.

LEVEL OF EVIDENCE

4.

Fracture Risk Assessment in Long-term Care (FRAiL): Development and Validation of a Prediction Model

Background

Strategies used to predict fracture in community-dwellers may not be useful in the nursing home (NH). Our objective was to develop and validate a model (Fracture Risk Assessment in Long-term Care [FRAiL]) to predict the 2-year risk of hip fracture in NH residents using readily available clinical characteristics.

Methods

The derivation cohort consisted of 419,668 residents between May 1, 2007 and April 30, 2008 in fee-for service Medicare. Hip fractures were identified using Part A diagnostic codes. Resident characteristics were obtained using the Minimum Data Set and Part D claims. Multivariable competing risk regression was used to model 2-year risk of hip fracture. We validated the model in a remaining 1/3 sample (n = 209,834) and in a separate cohort in 2011 (n = 858,636).

Results

Mean age was 84 years (range 65-113 years) and 74.5% were female. During 1.8 years mean follow-up, 14,553 residents (3.5%) experienced a hip fracture. Fifteen characteristics in the final model were associated with an increased risk of hip fracture including dementia severity, ability to transfer and walk independently, prior falls, wandering, and diabetes. In the derivation sample, the concordance index was 0.69 in men and 0.71 in women. Calibration was excellent. Results were similar in the internal and external validation samples.

Conclusions

The FRAiL model was developed specifically to identify NH residents at greatest risk for hip fracture, and it identifies a different pattern of risk factors compared with community models. This practical model could be used to screen NH residents for fracture risk and to target intervention strategies.

Gout and Risk of Fracture in Women: A Prospective Cohort Study

OBJECTIVE

Uric acid may be linked to bone health through its antioxidant or prooxidant effects, thereby affecting bone resorption and formation, or through its dual inhibition of vitamin D activation and parathyroid hormone production. Results of prior studies on the relationship between uric acid and bone mineral density have been conflicting. This prospective study was undertaken to examine the relationship between gout, a disease characterized by hyperuricemia and inflammation, and risk of hip or wrist fracture in women.

METHODS

We conducted a prospective observational study of gout and risk of incident wrist and hip fracture in women participating in the Nurses' Health Study (n = 103,799 at baseline, with 14 years of follow-up for the wrist fracture analysis and 22 years of follow-up for the hip fracture analysis). Gout history and incident cases of wrist and hip fracture were assessed by biennial questionnaire. Cox proportional hazards models were used to simultaneously adjust for potential confounders.

RESULTS

In this cohort, there were 3,769 incident wrist fractures (1990-2004) and 2,147 incident hip fractures (1990-2012), with 107 wrist fractures and 117 hip fractures occurring in participants with gout. In those women with a history of gout compared with women without gout, the multivariable-adjusted relative risk of wrist fracture was 1.12 (95% confidence interval [95% CI] 0.92-1.36) and the multivariable-adjusted relative risk of hip fracture was 1.38 (95% CI 1.14-1.68).

CONCLUSION

In women, a history of gout is associated with a modestly increased risk of hip fracture, but not significantly associated with a risk of wrist fracture.

Preference for wine is associated with lower hip fracture incidence in post-menopausal women

BACKGROUND

Past studies of relationships between alcohol and hip fracture have generally focused on total alcohol consumed and not type of alcohol. Different types of alcohol consist of varying components which may affect risk of hip fracture differentially. This study seeks to examine the relationship between alcohol consumption, with a focus on type of alcohol consumed (e.g. beer, wine, or hard liquor) and hip fracture risk in post-menopausal women.

METHODS

The longitudinal cohort consisted of U.S. post-menopausal women aged 50-79 years enrolled between 1993-1998 in the Women's Health Initiative Clinical Trials and Observational Study (N=115,655).

RESULTS

Women were categorized as non-drinkers, past drinkers, infrequent drinkers and drinkers by preference of alcohol type (i.e. those who preferred wine, beer, hard liquor, or who had no strong preference). Mean alcohol consumption among current drinkers was 3.3 servings per week; this was similar among those who preferred wine, beer and liquor. After adjustment for potential confounders, alcohol preference was strongly correlated with hip fracture risk (p = 0.0167); in particular, women who preferred wine were at lower risk than non-drinkers (OR=0.78; 95% CI 0.64-0.95), past drinkers (OR=0.85; 95% CI 0.72-1.00), infrequent drinkers (OR=0.73; 95% CI 0.61-0.88), hard liquor drinkers (OR=0.87; 95% CI 0.71-1.06), beer drinkers (OR=0.72; 95% CI 0.55-0.95) and those with no strong preference (OR=0.89; 95% CI 0.89; 95% CI 0.73-1.10).

CONCLUSIONS

Preference of alcohol type was associated with hip fracture; women who preferentially consumed wine had a lower risk of hip fracture compared to non-drinkers, past drinkers, and those with other alcohol preferences.

The impact of osteoporosis prevention programs on calcium intake: a systematic review

Little is known about the dimensions of osteoporosis prevention programs essential to changing health behaviors. The purpose of this review was to determine the impact of select characteristics of structured osteoporosis prevention programs on calcium intake in women. This systematic review included 12 experimental and quasi-experimental studies conducted internationally with adult women participants. Studies were more likely to demonstrate differences when they were conducted outside the U.W.; participants had lower baseline calcium intake; and interventions were multi-dimensional and included factual information, skill training, and social contact delivered dynamically over time. The results document extensive variability across participants, programs, and measures. There is a need to document the source (total and sub-total) of calcium intake, to provide the necessary data to calculate effect sizes to enable comparison across studies, and to identify those moderating factors (such as menopausal status) that affect the ability to determine differences between sub-groups. Results indicate health behavior change is more likely to occur when patient-centered interventions designed to increase knowledge and health beliefs, skills and abilities, and social facilitation are delivered over time. There is an urgent need for the development and testing of new health behavior change theories, prevention programs, and delivery media to support and complement health care providers in the prevention and management of this common, debilitating condition.

A displaced femoral neck stress fracture in an amenorrheic adolescent female runner

This case demonstrates the potential serious consequences of the female athlete triad and its effects on bone. Displaced femoral neck stress fractures cause significant morbidity, and this case highlights the preventable nature of this injury. The treatment was focused on improving low energy availability, and, although challenging, improvements were made. This injury could have been prevented if the signs and symptoms of her injury had been addressed and there had been better knowledge of her risk factors. This case highlights the need for further education in the sports and health communities.

A survey of screening and practice patterns used for patients with osteoporosis in a sample of physical therapists from Illinois

BACKGROUND

Physical therapists provide care for many patients who are at risk or have been diagnosed with osteoporosis. Currently, little information exists about what physical therapists know about osteoporosis, how they screen for the condition, and how they manage patients with osteoporosis.

PURPOSE

This study assessed knowledge and confidence of physical therapists in screening, examining, and planning interventions for persons diagnosed or at risk for osteoporosis.

METHODS

A survey was mailed to 250 randomly selected members of the Illinois Physical Therapy Association. A follow-up mailing was sent to those who had not replied within 3 months. Survey items focused knowledge and confidence with screening and developing interventions for persons with osteoporosis. Response rate was 41% with a final sample of 83, 3 respondents meeting the inclusion criterion (working with women age 40-90).

RESULTS

The majority of respondents were confident (35%) or somewhat confident (47%) in their ability to recognize risk factors for osteoporosis. The majority correctly identified female gender (68%), history of fracture (88%), and family history of osteoporosis (80%) as risk factors for osteoporosis, and identified changes in height (86%), and changes in posture (90%) as indicators for screening. Only 35% would often or always identify Asian American individuals as appropriate for screening for osteoporosis. Respondents appropriately prescribed log rolling for bed mobility (82%), rest in a supine position (45%), "hip hinge" as a method for sit to stand (48%), and wall slides (52%). Although more than 55% reported never prescribing high-risk exercises such as toe touches, abdominal machines, or abdominal crunches, 33% would prescribe high-risk exercises such as rest in a sitting position (37%) and a "nose over toes" method of sit-stand (36%).

CONCLUSION

It appears physical therapists correctly screen and identify some risk factors for osteoporosis; more education is needed in certain areas of screening and interventions for those with osteoporosis.

Osteoprotegerin, RANKL and bone turnover in postmenopausal osteoporosis

Background

Osteoprotegerin (OPG) and receptor activator of nuclear factor κ B ligand (RANKL) play a critical role in the regulation of bone turnover, but the relative importance of these two cytokines in the pathogenesis of postmenopausal osteoporosis is controversial.

Aim

To investigate the relationship between circulating levels of OPG, RANKL, bone turnover and bone mineral density (BMD) in postmenopausal women.

Methods

A cross-sectional study of 185 women with osteoporosis and 185 age- and sex-matched control subjects was undertaken. Measurements were made of plasma OPG, RANKL, interleukin-6 (IL-6), sex steroids, calciotropic hormones, biochemical markers of bone turnover, BMD and anthropometry. Health questionnaires were administered.

Results

Plasma RANKL was significantly higher (p<0.0001) in women with osteoporosis (0.66±0.67 pmol/l) than in control subjects (0.37±0.38 pmol/l), as was plasma OPG (18.70±9.70 pmol/l in women with osteoporosis, 10.44±5.85 pmol/l in control subjects; p<0.0001). OPG/RANKL ratio was higher in women with osteoporosis (51.3) than in control subjects (36.6). The women with osteoporosis also had significantly higher biochemical markers of bone turnover, IL-6 and parathyroid hormone and lower 25-hydroxyvitamin D and oestradiol than the control subjects. Multiple regression analysis showed that lumbar spine and femoral neck BMD in postmenopausal women were best predicted by OPG and RANKL, giving an R2 value of 15.5% and 14.9%, respectively.

Conclusions

This study indicates that the circulating levels of OPG and RANKL are inversely related to BMD and contribute to the development of osteoporosis in postmenopausal women.

Cross-sectional evidence of suppressed bone mineral accrual among female adolescent runners

We aimed to evaluate patterns of bone mineral accrual among a cross-sectional sample of female adolescent runners and girls participating in a nonendurance running sport. One-hundred and eighty-three interscholastic competitive female athletes (age 16.0 +/- 0.1 years), 93 endurance runners and 90 nonrunners, completed a menstrual and sports history questionnaire, had their height and weight measured, and underwent a dual-energy X-ray absorptiometry scan for the measurements of body composition and bone mass. For the majority of analyses, the girls were separated into four groups according to their age (13 to 14 years, 15 years, 16 years, and 17 to 18 years). Runners' height, weight, body mass index (BMI), percent body fat, lean tissue mass, number of menstrual cycles in the past year, and months of participation in a non-lean-build/variable-impact-loading sport were significantly lower than mean values for nonrunners. Although bone mass rose at all sites in the nonrunners between the ages of 13 to 14 years and 17 to 18 years, no such increase was noted in the runners. Runners compared with nonrunners exhibited significantly lower body weight and height-adjusted total body and lumbar spine bone mineral content (BMC) values and lower bone mineral density (BMD) Z-score values among the older (16 years and/or 17 to 18 years) but not younger (13 to 14 years and/or 15 years) age groups. These findings suggest that the runners, in contrast to the nonrunners, exhibited a suppressed bone mineral accrual pattern, which supports the notion that female adolescent endurance runners may be at risk for inadequate bone mass gains and thus a low peak BMD.

Prognostic factors for skeletal complications from metastatic bone disease in breast cancer

Skeletal morbidity is common in patients with bone metastases from breast cancer (BC) and can undermine patients' functional independence and quality of life. Previously defined prognostic factors may not reflect current treatment standards and the use of antiresorptive therapies. We report a comprehensive multivariate analysis of potential prognostic factors for skeletal-related events (SREs) using data from a phase III, randomized study of zoledronic acid in patients with bone metastases from BC. The trial evaluated the number and timing of SREs (pathologic fracture, palliative radiotherapy to bone, surgery to bone to treat or prevent a fracture, and spinal cord compression) and assessed variables for prognostic significance in univariate and multivariate Cox-regression analyses. Continuous variables were categorized with predefined cutpoints. All associations with P < 0.05 were considered significant. A total of 444 zoledronic acid-treated patients with assessments of biochemical markers of bone metabolism and complete baseline variable data were included. Significant baseline prognostic factors for occurrence of a first SRE by multivariate analyses included age, pain score, prior history of an SRE, predominant lesion type, elevated bone-specific alkaline phosphatase, and lactate dehydrogenase. Prior fracture was found to be prognostic in a reduced multivariate analysis of time to first fracture, but not for time to first palliative radiotherapy. In conclusion, this model identified several prognostic factors that may be useful in routine clinical care. Validation of these factors in a separate dataset and generation of a prognostic risk score are recommended next steps.

Variation in risk factors for fractures at different sites

Fractures in older people are important medical problems. Knowledge of risk factors is essential for successful preventive measures, but when fracture sites of diverse etiology are combined, risk factors for any one site are difficult to identify and may be missed entirely. Among older people, incidence rates of hip, proximal humerus, and vertebral fractures increase with age, but not rates of distal forearm and foot fractures. Low bone mineral density is strongly associated with hip, distal forearm, vertebral, and proximal humerus fractures, but not foot fracture. Most fractures of the hip, distal forearm, and proximal humerus result from a fall, whereas smaller proportions of fractures of the foot and vertebrae follow a fall. Frail people are likely to fracture their hip or proximal humerus, while healthy, active people tend to fracture their distal forearm. We strongly recommend that studies identify risk factors on a site-specific basis.