Reproducibility of a questionnaire on risk factors for osteoporosis in a multicentre prevalence survey: the European Vertebral Osteoporosis Study

Damaged bone microarchitecture by Trabecular Bone Score (TBS) and low appendicular muscle mass: main risk factors for vertebral and non-vertebral fractures in women with long-standing rheumatoid arthritis

We ascertained the fracture risk factors stratified by vertebral and non-vertebral sites in rheumatoid arthritis (RA) females. Bone/muscle features, but not disease activity, were the main markers for fractures in this long-standing RA population: low trabecular bone score (TBS) for vertebral fracture and decreased appendicular muscle mass for non-vertebral fracture.

PURPOSE

To assess risk factors for fractures, including clinical, laboratory and dual energy X-ray absorptiometry (DXA) parameters (bone mass, trabecular bone score-TBS, muscle mass) in women with established rheumatoid arthritis (RA).

METHODS

Three hundred females with RA (ACR, 2010) were studied. Clinical data were obtained by questionnaire and disease activity by composite indices (DAS28, CDAI, SDAI), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Bone mineral density (BMD), TBS, body composition and Vertebral Fracture Assessment (VFA) were performed by DXA. Logistic regression models were constructed to identify factors independently associated with vertebral (VF) and non-vertebral fractures (NVF), separately.

RESULTS

Through rigorous eligibility criteria, a total of 265 women were yielded for final data analysis (median age, 55 [22-86] years; mean disease duration, 16.2 years). Prevalence of VF and NVF were 30.6% and 17.4%, respectively. In multivariate analyzes, TBS (OR = 1.6, 95%CI = 1.09-2.36, p = 0.017), CRP (OR = 1.54, 95%CI = 1.15-2.08, p = 0.004), and parathormone (OR = 1.24, 95%CI = 1.05-1.45, p = 0.009) were risk factors for VF, whereas low appendicular muscle mass (OR = 2.71; 95%CI = 1.01-7,28; p = 0.048), body mass index (BMI) (OR = 0.90, 95%CI = 0.82-0.99; p = 0.025), ESR (OR = 1.18, 95%CI = 1.01-1,38, p = 0,038) and hip BMD (OR = 1.82, 95%CI = 1.10-3.03, p = 0.02) were associated with NVF.

CONCLUSION

In women with long-term RA, markers of fractures differed between distinct skeletal sites (vertebral and non-vertebral). The magnitude of association of bone/muscle parameters with fracture (TBS for VF and appendicular muscle mass for NVF) was greater than that of the association between RA activity and fracture. TBS seems to have greater discriminative power than BMD to identify subjects with VF in long-standing RA.

Associations of Bone Mineral Density with RANKL and Osteoprotegerin in Arab Postmenopausal Women: A Cross-Sectional Study

Background and objective: There is limited information as to the association of several key bone markers with bone mineral density (BMD) in understudied ethnic groups. This study investigated the relationship between circulating levels of osteoprotegerin (OPG) and receptor activator of nuclear factor kappa-Β ligand (RANKL) with BMD in Arab postmenopausal women. Materials and methods: In this cross-sectional study, a total of 617 Saudi postmenopausal women from the Osteoporosis Registry of the Chair for Biomarkers of Chronic Diseases were included. Anthropometric data, BMD, and biochemical data were retrieved from the registry. Participants were stratified into three groups based on T-score; n = 169 with osteoporosis, n = 282 with osteopenia, and n = 166 normal. Analysis of bone markers including RANKL, OPG, osteocalcin, and N-terminal telopeptide (NTx) was completed using commercially available bioassays. Results: The results suggested that OPG was significantly and positively correlated with age in the osteoporosis group (r = 0.29, p < 0.05), while it was inversely correlated with BMD femoral neck left (r = −0.56, p < 0.001) and BMD femoral neck right (r = −0.37, p < 0.05) in the same group. Moreover, RANKL showed a significant inverse correlation with NTx in the osteopenia group (r = −0.37, p < 0.05). Furthermore, the RANKL/OPG ratio had a positive and significant correlation with BMI (r = 0.34, p < 0.05), BMD femoral neck left (r = 0.36, p < 0.05) and BMD femoral neck right (r = 0.35, p < 0.05) in the osteopenia group. By contrast, it showed a significant inverse correlation with waist to hip ratio in the osteoporosis group (r = −0.38, p < 0.05). Multiple regression analysis showed that OPG contributes to BMD variations in the osteopenia group (p = 0.03). Conclusions: In conclusion, changes in circulating levels of RANKL and OPG might be a protective mechanism contrary to the increased bone loss in postmenopausal women.

Analysis of the physiological load on lumbar vertebrae in patients with osteoporosis: a finite-element study

This study aims to investigate the difference in physiological loading on the spine in three different motions (flexion-extension, lateral bending, and axial rotation) between osteoporotic and normal spines, using finite element modelling. A three-dimensional finite element (FE) model centered on the lumbar spine was constructed. We applied two different material properties of osteoporotic and normal spines. For the FE analysis, three loading conditions (flexion-extension, lateral bending, and axial rotation) were applied. The von Mises stress was higher on the nucleus pulposus at all vertebral levels in all movements, in the osteoporosis group than in the normal group. On the annulus fibrosus, the von Mises stress increased at the level of L3-L4, L4-L5, and L5-S in the flexion-extension group and at L4-L5 and L5-S levels in the lateral bending group. The values of two motions, flexion-extension and lateral bending, increased in the L4 and L5 cortical bones. In axial rotation, the von Mises stress increased at the level of L5 of cortical bone. Additionally, the von Mises stress increased in the lower endplate of L5-S and L4-L5 in all movements, especially lateral bending. Even in the group with no increase, there was a part that received increased von Mises stress locally for each element in the three-dimensional reconstructed view of the pressure distribution in color. The von Mises stress on the lumbar region in the three loading conditions, was greater in most components of osteoporotic vertebrae than in normal vertebrae and the value was highest in the nucleus pulposus. Considering the increase in the measured von Mises stress and the local increase in the pressure distribution, we believe that these results can contribute to explaining discogenic pain and degeneration.

Night shift work and osteoporosis - bone turnover markers among female blue-collar workers in Poland

Osteoporosis is an important public health problem worldwide. Although many factors relating to bone structure have been described so far, the current knowledge on the occupational factors that may affect bone tissue metabolism is strongly limited. Literature data suggest that night shift work, via circadian rhythm disruption, may be considered a potential risk factor. To this date, only five epidemiological studies addressing this problem have been conducted worldwide. The outcomes of three studies confirmed such relationship, namely, a higher fracture risk was found among nurses with a long lifetime duration of night shift work in one study; and a lower bone mineral density was associated with occupational activity during night-time in two studies. In adults, the bone undergoes constant remodelling through bone resorption followed by bone formation. The various molecules released into the circulatory system during these processes are called bone turnover markers. We investigated the possible associations between night shift work and selected bone turnover markers: N-terminal propeptide of type I procollagen (P1NP), C-terminal cross-linked telopeptide of type I collagen (CTX), osteocalcin, osteopontin, fibroblast growth factor 23 (FGF-23) and osteoprotegerin, measured in plasma of 189 female blue-collar workers. A significantly higher bone turnover rate was noted among the women working night shifts than among those working only during the day. This may potentially lead to a future development of osteoporosis in this population even if the macroscopic changes in the bone structure are not detectable. Night shift work is a prevailing occupational characteristics nowadays. It has been estimated that about 15-20% of the working population in Europe and the USA perform work under this system. Thus, the problem of osteoporosis can affect a large part of the working-age population.

Can local staff reliably assess their own programs? A confirmatory test-retest study of Lot Quality Assurance Sampling data collectors in Uganda

Background

Methods

Results

Conclusion

Electronic supplementary material

Vertebral Scheuermann's disease in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over

In 27 centres across Europe, the prevalence of deforming spinal Scheuermann's disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8% in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann's, helping the differential diagnosis from osteoporosis.

INTRODUCTION

This study aims to assess the prevalence of Scheuermann's disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture.

METHODS

In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann's disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl's node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2-L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann's by alternative published algorithms when these used the radiographic signs we assessed.

RESULTS

Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann's varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8% with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann's was not associated with BMD of the spine or hip.

CONCLUSIONS

Since most of the variation in population impact of Scheuermann's was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.

Normocalcaemic hypoparathyroidism: prevalence and effect on bone status in older women. The OPUS study

OBJECTIVE

There are no consistent data on the prevalence and bone status of normocalcaemic hypoparathyroidism (NHYPO) as defined by normal adjusted calcium and low PTH level. Our aim was to determine the prevalence and the metabolic bone profile of NHYPO in older women, assessing its evolution over time. The second objective was to evaluate the prevalence of other calcium metabolic disorders.

DESIGN

The Osteoporosis and Ultrasound Study (OPUS) is a 6-yr prospective study of fracture-related factors.

PARTICIPANTS

A total of 2419 older women (age 55-79 yrs) and 258 younger women (age 30-40 yrs) participated. Complete follow-up data were available in 1416 subjects.

MEASUREMENTS

After calculating the adjusted calcium according to James' formula, we identified 'abnormal' calcium and PTH using Mahalanobis distances and allocated older women into different pathological categories using reference intervals from the healthy young women.

RESULTS

We identified 57 subjects with NHYPO (2·4%). These women had lower than expected bone turnover as assessed by bone alkaline phosphatase (-14·5%, 95% CI: -26·2 to -3·0, P = 0·007), CTX (-66·3%, 95% CI: -74·0 to -56·4, P < 0·001) and osteocalcin (-36·8%, 95% CI: -45·6 to -26·6, P < 0·001). After 6 years, of the 35 NHYPO subjects with follow-up data, none developed overt hypoparathyroidism and only 15 (0·6%) subjects had persistent evidence of NHYPO. We also identified 86 subjects (3·6%) affected by hyperparathyroid hypercalcaemia.

CONCLUSION

This is the first large population-based study to investigate NHYPO in older women. NHYPO is fairly common, not always persistent and is characterized by low bone turnover.

Sonographic assessment of healthy peripheral joints: evaluation according to demographic parameters

OBJECTIVES

To describe quantitative and semiquantitative sonographic joint measurements in healthy adults and compare them with demographic parameters.

METHODS

A cross-sectional study was conducted. Bilateral sonographic measurements of small, medium, and large joints were performed in 130 healthy volunteers, stratified into 5 age groups (A, 18-29; B, 30-39; C, 40-49; D, 50-59; and E, 60-80 years). Quantitative synovial hypertrophy measurements and semiquantitative synovial hypertrophy, power Doppler, bone erosion (score 0-3), and articular cartilage (score 0-4) measurements were performed by a blinded radiologist using a 6-18-MHz linear array transducer. The sonographic measurements were correlated with demographic parameters. The significant P value was set at .05.

RESULTS

A total of 6500 joint recesses were studied; the mean age ± SD of the participants was 44.8 ± 14.6 years, and 76.9% were women. The highest quantitative synovial hypertrophy values were found in the hip (6.4 mm) and talonavicular joint (2.6 mm). The joint recesses with a greater frequency of hypothetical pathologic semiquantitative scores were second metatarsophalangeal (78.8%) and first metatarsophalangeal (69.3%) for synovial hypertrophy, radiocarpal (17.7%) and first metatarsophalangeal (15.8%) for power Doppler, and posterior glenohumeral (23.1%) and ulnocarpal (4.2%) for bone erosion. The highest quantitative synovial hypertrophy values and the lowest semiquantitative synovial hypertrophy, power Doppler, bone erosion, and articular cartilage scores were observed in age group E (P < .046). There were positive correlations between the sonographic measurements and height, age, weight, and body mass index in 30.4%, 34.8%, 43.5%, and 47.8%, respectively, of all the joint recesses studied.

CONCLUSIONS

Sonographic changes in healthy peripheral joints were observed predominantly in the oldest group.

Establishing reference intervals for bone turnover markers in healthy postmenopausal women in a nonfasting state

In order to interpret bone turnover markers (BTMs), we need to establish healthy reference intervals. It is difficult to establish reference intervals for older women because they commonly suffer from diseases or take medications that affect bone turnover. The aims of this study were: (1) to identify diseases and drugs that have a substantial effect on BTMs; (2) to establish reference intervals for premenopausal and postmenopausal women; and (3) to examine the effects of other factors on BTMs in healthy postmenopausal women. We studied women aged 30-39 years (n=258) and women aged 55-79 years (n=2419) from a five-European centre population-based study. We obtained a nonfasting serum and second morning void urine samples at a single baseline visit. BTMs were measured using automated immunoassay analysers. BTMs were higher in patients with vitamin D deficiency and chronic kidney disease. Three or more BTMs were higher in women who were osteoporotic and at least two BTMs were lower in women who were oestrogen replete, taking osteoporosis treatments or having diseases known to affect bone turnover. These were used as exclusion criteria for selecting the populations for the reference intervals. The reference intervals for BTMs were higher in postmenopausal than premenopausal women. Levels of BTMs were not dependent on geographical location and increased with age.

Peripheral quantitative computed tomography measures are associated with adult fracture risk: the Hertfordshire Cohort Study

Peripheral quantitative computed tomography (pQCT) captures novel aspects of bone geometry that may contribute to fracture risk and offers the ability to measure both volumetric bone mineral density (vBMD) and a separation of trabecular and cortical compartments of bone, but longitudinal data relating measures obtained from this technique to incident fractures are lacking. Here we report an analysis from the Hertfordshire Cohort Study, where we were able to study associations between measures obtained from pQCT and DXA in 182 men and 202 women aged 60-75 years at baseline with incident fractures over 6 years later. Among women, radial cortical thickness (HR 1.72, 95% CI 1.16, 2.54, p=0.007) and cortical area (HR 1.91, 95% CI 1.27, 2.85, p=0.002) at the 66% slice were both associated with incident fractures; these results remained significant after adjustment for confounders (age, BMI, social class, cigarette smoking and alcohol consumption, physical activity, dietary calcium, HRT and years since menopause). Further adjustment for aBMD made a little difference to the results. At the tibia, cortical area (HR 1.58, 95% CI 1.10, 2.28, p=0.01), thickness (HR 1.49, 95% CI 1.08, 2.07, p=0.02) and density (HR 1.64, 95% CI 1.18, 2.26, p=0.003) at the 38% site were all associated with incident fractures with the cortical area and density relationships remaining robust to adjustment for the confounders listed above. Further adjustment for aBMD at this site did lead to attenuation of relationships. Among men, tibial stress-strain index (SSI) was predictive of incident fractures (HR 2.30, 95% CI 1.28, 4.13, p=0.005). Adjustment for confounding variables and aBMD did not render this association non-significant. In conclusion, we have demonstrated relationships between measures of bone size, density and strength obtained by pQCT and incident fracture. These relationships were attenuated but in some cases remained significant after adjustment for BMD measures obtained by DXA, suggesting that some additional information may be conferred by this assessment.

Prevalence and determinants of osteoporosis in patients with type 1 and type 2 diabetes mellitus

BACKGROUND

Increased risk of osteoporosis and its clinical significance in patients with diabetes is controversial. We analyze osteoporosis prevalence and determinants of bone mineral density (BMD) in patients with type 1 and 2 diabetes.

METHODS

Three hundred and ninety-eight consecutive diabetic patients from a single outpatient clinic received a standardized questionnaire on osteoporosis risk factors, and were evaluated for diabetes-related complications, HbA1c levels, and lumbar spine (LS) and femoral neck (FN) BMD. Of these, 139 (71 men, 68 women) type 1 and 243 (115 men, 128 women) type 2 diabetes patients were included in the study. BMD (T-scores and values adjusted for age, BMI and duration of disease) was compared between patient groups and between patients with type 2 diabetes and population-based controls (255 men, 249 women).

RESULTS

For both genders, adjusted BMD was not different between the type 1 and type 2 diabetes groups but was higher in the type 2 group compared with controls (p < 0.0001). Osteoporosis prevalence (BMD T-score < -2.5 SD) at FN and LS was equivalent in the type 1 and type 2 diabetes groups, but lower in type 2 patients compared with controls (FN: 13.0% vs 21.2%, LS: 6.1% vs 14.9% men; FN: 21.9% vs 32.1%, LS: 9.4% vs 26.9% women). Osteoporosis prevalence was higher at FN-BMD than at LS-BMD. BMD was positively correlated with BMI and negatively correlated with age, but not correlated with diabetes-specific parameters (therapy, HbBA1c, micro- and macrovascular complications) in all subgroups. Fragility fracture prevalence was low (5.2%) and not different between diabetes groups. Fracture patients had lower BMDs compared with those without fractures; however, BMD T-score was above -2.5 SD in most patients.

CONCLUSIONS

Diabetes-specific parameters did not predict BMD. Fracture occurrence was similar in both diabetes groups and related to lower BMD, but seems unrelated to the threshold T-score, <-2.5 SD. These results suggest that osteoporosis, and related fractures, is a clinically significant and commonly underestimated problem in diabetes patients.

Oxytocin, a new determinant of bone mineral density in post-menopausal women: analysis of the OPUS cohort

INTRODUCTION

Oxytocin (OT), a neurohypophysial hormone regulated by estrogen and leptin, may play a role in bone metabolism in humans as suggested by animal studies. This study assessed the relationship between OT and bone status in a large population of postmenopausal women.

SUBJECTS AND METHODS

Subjects were included in the Osteoporosis and Ultrasound study, a 6-year prospective study in a population-based cohort. Final visit data were used for this cross-sectional study. OT, leptin, and estradiol serum levels were measured in 1097 postmenopausal women and compared with bone mineral density (BMD), fractures, and the bone turnover markers (BTMs) procollagen type 1 N-terminal propeptide, bone alkaline phosphatase, and C-telopeptide of type 1 collagen.

RESULTS

The median age was 70.8 years, 16% were osteoporotic, 48% were osteopenic, and 29% had at least one fracture. The OT serum level was related to spine (r = +0.12, P = .0002) and total hip BMD (r = +0.21, P < .0001) and with BTM (procollagen type 1 N-terminal propeptide: r = -0.13, P < .0001, bone alkaline phosphatase: r = -0.07, P = .02, C-telopeptide of type 1 collagen: r = -0.18, P < .0001). The relationship of OT with BMD was independent of BTM. After adjustment for confounding factors, the correlation between OT serum level and BMD remains significant at the hip in women with unmeasurable estradiol or leptin above the median value. There was no significant relationship between OT serum levels and fractures.

CONCLUSION

High OT levels are associated with high BMD, especially at the hip in women with low estradiol or high leptin serum levels. The mechanism may be explained by the effect of OT on bone turnover.

Can health workers reliably assess their own work? A test-retest study of bias among data collectors conducting a Lot Quality Assurance Sampling survey in Uganda

BACKGROUND

Lot Quality Assurance Sampling (LQAS) is a classification method that enables local health staff to assess health programmes for which they are responsible. While LQAS has been favourably reviewed by the World Bank and World Health Organization (WHO), questions remain about whether using local health staff as data collectors can lead to biased data.

METHODS

In this test-retest research, Pallisa Health District in Uganda is subdivided into four administrative units called supervision areas (SA). Data collectors from each SA conducted an LQAS survey. A week later, the data collectors were swapped to a different SA, outside their area of responsibility, to repeat the LQAS survey with the same respondents. The two data sets were analysed for agreement using Cohens' kappa coefficient and disagreements were analysed.

RESULTS

Kappa values ranged from 0.19 to 0.97. On average, there was a moderate degree of agreement for knowledge indicators and a substantial level for practice indicators. Respondents were found to be systematically more knowledgeable on retest indicating bias favouring the retest, although no evidence of bias was found for practices indicators.

CONCLUSIONS

In this initial study, using local health care providers to collect data did not bias data collection. The bias observed in the knowledge indicators is most likely due to the 'practice effect', whereby respondents increased their knowledge as a result of completing the first survey, as no corresponding effect was seen in the practices indicators.

Bone mineral density measurements, bone markers and serum vitamin D concentrations in men with chronic non-cirrhotic untreated hepatitis C

Introduction

The high prevalence of chronic hepatitis C (CHC) and its consequent cirrhosis has been associated with bone fragility. Whether CHC may cause bone and mineral abnormalities in the absence of hepatocellular dysfunction is still unknown. In this study we aimed to determine the prevalence of osteoporotic vertebral fractures and low BMD measurements in men with non-cirrhotic CHC. Risk factors for low BMD and fractures were also investigated.

Methods

Morphometric vertebral fractures and BMD measurements were performed in 60 non-cirrhotic untreated men with CHC and 59 healthy controls, matched for age and gender, weight and current smoking. Serum CTx, calcium, phosphate, intact PTH, alkaline phosphatase and vitamin D (25OHD) concentrations were measured in all participants. Clinical risk factors for low BMD and fractures were evaluated by a structured questionnaire as well as details regarding HCV infection.

Results

Trochanter and total femur BMD were significantly lower in CHC patients as compared to healthy men (p = 0.04). In men 50 years and older, the prevalence of osteoporosis was significantly higher among CHC patients (p = 0.01). Lower levels of physical activities and more often report of prolonged immobilization were observed among CHC patients (p<0.05). Liver inflammation and fibrosis, viral load and genotype did not correlate with BMD measurements. Bone markers and 25OHD concentrations were similar in both groups. Only a few vertebral fractures were observed.

Conclusions

Our results demonstrate that non-cirrhotic untreated CHC patients have lower BMD at the femur as compared to healthy men in spite of the absence of significant bone and mineral abnormalities.

Prevalence and risk factors associated with low-impact fractures in men with rheumatoid arthritis

The aim of this study is to describe the prevalence of fractures in men with rheumatoid arthritis (RA) and identify potential risk factors associated with skeletal fragility. We consecutively studied 50 men with RA. Clinical risk factors were evaluated by clinical questionnaire, functional capacity by M-HAQ1, and disease activity by DAS-28. RA men were compared to 52 healthy controls paired for age and BMI. Bone mineral density (BMD) and quantitative ultrasound (QUS) at the heel were performed in all participants. Morphometric vertebral fractures (VF) were classified by a semiquantitative method. Men with RA were 51.7 years old on average and had mean disease duration of 115 months. Fragility fractures were found in 40% of individuals, of which 36% were VF, significantly higher than in healthy controls (p < 0.01). Age, anthropometric data, and lifestyle were similar between RA men with and without fractures. About 94% of the men with RA were on long-term glucocorticoid (GC) use. Patients with fractures were more frequently positive for rheumatoid factor (RF), had longer morning stiffness, and higher DAS-28 when compared to patients without fractures (p ≤ 0.05). In addition, they had significantly lower spine and hip BMD as well as a lower stiffness index (p ≤ 0.05). There was no statistically significant correlation between fracture and cumulative GC use. The final model of logistic regression showed a significant association and interaction between lower weight and physical activity in men with RA and fragility fractures. RA in men as well as in women is a risk factor for fragility fractures. The risk of fractures is higher in patients with positive RF, prolonged morning stiffness, higher scores of disease activity, and lower values of BMD and QUS.

Vitamin D status and the Cdx-2 polymorphism of the vitamin D receptor gene are determining factors of bone mineral density in young healthy postmenopausal women

Bone mineral density (BMD) is a main determinant of osteoporotic fractures. A cross-sectional study was conducted in 229 young, healthy postmenopausal women (PMW) to evaluate the contribution of the vitamin D endocrine system and other clinical, biochemical and genetic parameters. Clinical risk factors for osteoporosis were obtained by a questionnaire. Serum concentrations of 25OHD, 1,25(OH)2D, PTH, and bone turnover markers were measured. The BsmI, FokI and Cdx-2 polymorphisms of the vitamin D receptor (VDR) gene were determined. DXA and the WHO criteria were applied for the diagnosis of osteoporosis. Univariate logistic and multivariate logistic regression analyses were carried out.

RESULTS

The prevalence of vitamin D deficiency (<50nmol/l) was 50%. Age increased osteoporosis risk; whereas body mass index (BMI), number of reproductive years, 25OHD level and the Cdx-2 polymorphism in the VDR gene (when allele A is present) were found to be protective. Therefore, both serum 25OHD and VDR polymorphism should be taken into account in the evaluation and implementation of therapeutic strategies concerning PMW, especially as the prevalence of vitamin D deficiency is still alarmingly high even at Southern latitudes. This article is part of a Special Issue entitled 'Vitamin D Workshop'.

Lower vitamin E serum levels are associated with osteoporosis in early postmenopausal women: a cross-sectional study

The aim of this study was to evaluate the relationship between vitamin E status and osteoporosis in early postmenopausal women. Anthropometric data, osteoporosis risk factors, vitamin E serum levels, bone mineral density (BMD) and other serum parameters which may influence bone mineral density in postmenopausal women were analyzed in a cross-sectional study. The association between osteoporosis and age, age of menopause, body mass index, osteocalcin, calcium, vitamin D, vitamin E (measured as 25 hydroxyvitamin D and as α-tocopherol:lipids ratio, respectively), bone alkaline phosphatase, smoking status, leisure physical activity and alcohol intake were modeled by a multivariate logistic regression and multi-linear regression analysis in 232 early postmenopausal women. A lower vitamin E:lipid ratio was associated with osteoporosis in multivariate logistic regression. In a multivariate linear model with BMD of the lumbar spine as a dependent variable, the vitamin E:lipid ratio was clearly related with BMD of the lumbar spine (F ratio = 6.30, p = 0.002). BMD of the lumbar spine was significantly higher in the highest tertile of the vitamin E:lipid ratio than in the lowest tertile. The mean vitamin E:lipid ratio was significantly lower in osteoporotic postmenopausal women (T score ≤-2.5) (3.0 ± 0.6 μmol/mmol) than normal (neither osteoporotic nor osteopenic) postmenopausal women (T score >-1) (3.5 ± 0.7 μmol/mmol) using multivariable-adjusted BMD. These findings highlight that vitamin E may increase BMD in healthy postmenopausal women.

Vitamin D insufficiency together with high serum levels of vitamin A increases the risk for osteoporosis in postmenopausal women

Postmenopausal women who were vitamin D deficient and had high serum levels of retinol had an eight times higher risk of having osteoporosis. A high retinol level together with vitamin D deficiency/insufficiency is an additional risk factor for osteoporosis.

PURPOSE

The aim of this study was to evaluate the association between vitamin D deficiency/insufficiency and excess of vitamin A intake as an osteoporosis risk factor in healthy postmenopausal women

DESIGN

The design is a cross-sectional study of 232 healthy postmenopausal women.

METHODS

Bone mass was evaluated by dual energy X-ray absorptiometry. Serum calcium, albumin phosphorus, creatinine, total high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, and triglycerides analyzed by standard methods and retinol and 25-hydroxyvitamin D [25(OH)D] measured by an online solid-phase extraction coupled with high-pressure liquid chromatography-ultraviolet detection.

RESULTS

Prevalence of vitamin D deficiency [25(OH)D < 20 ng/mL] was 70.1 %; 14.3 % had a 25(OH)D < 10 ng/mL, and 23.6 % had insufficiency [25(OH)D 21-29 ng/mL]. Prevalence of high serum levels of retinol (>80 μg/dL) was 36.4 %. Among subjects with 25(OH)D <20 ng/mL (n = 152), 60.4 % (n = 92) had serum levels of retinol > 80 μg/dL. Bone density measurements revealed that the risk of osteoporosis was ~8 times higher in women with the highest retinol levels, as compared with women with the lowest retinol levels. In women with 25(OH)D < 20 ng/mL, the risk for osteoporosis increased substantially in women who had the highest blood levels of retinol compared to the women with lowest retinol levels.

CONCLUSIONS

Higher retinol levels together with vitamin D deficiency could be a significant additional risk factor for osteoporosis, underscoring the need for improved physician and public education regarding optimization of vitamin D status in postmenopausal women and developing policies to avoid high serum levels of vitamin A.

Higher prevalence of morphometric vertebral fractures in patients with recent coronary events independently of BMD measurements

Cardiovascular disease and osteoporosis are important causes of morbi-mortality in the elderly and may be mutually related. Low bone mineral density (BMD) may be associated with increased risk of cardiovascular events. We investigated the prevalence of low bone mass and fractures in metabolic syndrome patients with acute coronary events. A case-control study was conducted with 150 individuals (30-80years-old) with metabolic syndrome. Seventy-one patients had had an acute coronary syndrome episode in the last 6months (cases) and the remaining 79 had no coronary event (controls). Cases and controls were matched for gender, BMI and age. DXA measurements and body composition were performed while spine radiographs surveyed for vertebral fractures and vascular calcification. Biochemical bone and metabolic parameters were measured in all patients. No statistically significant difference in BMD and the prevalence of osteopenia, osteoporosis and non-vertebral fractures was observed between cases and controls. The prevalence of vertebral fractures and all fractures was higher in the cases (14.1 versus 1.3%, p=0.003 and 22.5versus7.6%, p=0.010, respectively). Male gender (OR=0.22 95% CI 0.58 to 0.83, p=0.026) and daily intake of more than 3 portions of dairy products (OR=0.19 95% CI 0.49 to 0.75, p=0.017) were associated with lower prevalence of fractures. Cases had higher risk for fractures (OR=4.97, 95% CI 1.17 to 30.30, p=0.031). Bone mass and body composition parameters were not associated with cardiovascular risk factors or bone mineral metabolism. Patients with fragility fractures had higher OPG serum levels than those without fractures (p<0.001). Our findings demonstrated that patients with recent coronary events have a higher prevalence of vertebral fractures independently of BMD.

Endogenous estradiol and the risk of incident fracture in postmenopausal women: the OPUS study

Some, but not all, studies have found that low endogenous estradiol levels in postmenopausal women are predictive of fractures. The aim of this study was to examine the roles of endogenous estradiol (E(2)), sex hormone binding globulin (SHBG), and dehydroepiandrosterone sulfate (DHEAS) in the prediction of incident vertebral and nonvertebral fractures. The study subjects were 797 postmenopausal women from the population-based OPUS (Osteoporosis and Ultrasound Study) study. Spine radiographs and dual-energy X-ray absorptiometry scans were obtained for all subjects at baseline and 6-year follow-up. Nonfasting blood samples were taken at baseline for E(2), SHBG, DHEAS, and bone turnover markers. Incident nonvertebral fractures were self-reported and verified; vertebral fractures were diagnosed at a single center from spinal radiographs. Medical and lifestyle data were obtained by questionnaire at each visit. Thirty-nine subjects had an incident vertebral fracture and 119 a nonvertebral fracture. Estradiol in the lowest quartile predicted vertebral fracture independent of confounders including age, body mass index, bone mineral density, bone turnover, fracture history, and use of antiresorptive therapy, with an OR of 2.97 (95 % confidence interval [CI] 1.52-5.82) by logistic regression. A calculated free estradiol index was not a stronger predictor than total E(2). Higher SHBG predicted vertebral fracture independently of age and body mass index, but not independently of E(2), bone mineral density, or prevalent fracture. Low DHEAS did not predict vertebral fracture. Nonvertebral fractures were not predicted by any of E(2), SHBG, or DHEAS, either in univariate or multivariate analyses. These findings suggest that there may be mechanistic differences in the protective effect of E(2) at vertebral compared with nonvertebral sites.

Development and validation of a tool for identifying women with low bone mineral density and low-impact fractures: the São Paulo Osteoporosis Risk Index (SAPORI)

The performance of the São Paulo Osteoporosis Risk Index (SAPORI) was tested in 1,915 women from the original cohort, São Paulo Osteoporosis Study (SAPOS) (N = 4332). This new tool was able to identify women with low bone density (spine and hip) and low-impact fracture, with an area under the receiving operator curve (ROC) of 0.831, 0.724, and 0.689, respectively.

INTRODUCTION

A number of studies have demonstrated the clinical relevance of risk factors for identifying individuals at risk of fracture (Fx) and osteoporosis (OP). The SAPOS is an epidemiological study for the assessment of risk factors for Fx and low bone density in women from the community of the metropolitan area of São Paulo, Brazil. The aim of the present study was to develop and validate a tool for identifying women at higher risk for OP and low-impact Fx.

METHODS

A total of 4,332 pre-, peri-, and postmenopausal women were analyzed through a questionnaire addressing risk factors for OP and Fx. All of them performed bone densitometry at the lumbar spine and proximal femur (DPX NT, GE-Lunar). Following the identification of the main risk factors for OP and Fx through multivariate and logistic regression, respectively, the SAPORI was designed and subsequently validated on a second cohort of 1,915 women from the metropolitan community of São Paulo. The performance of this tool was assessed through ROC analysis.

RESULTS

The main and significant risk factors associated with low bone density and low-impact Fx were low body weight, advanced age, Caucasian ethnicity, family history of hip Fx, current smoking, and chronic use of glucocorticosteroids. Hormonal replacement therapy and regular physical activity in the previous year played a protective role (p < 0.05). After the statistical adjustments, the SAPORI was able to identify women with low bone density (T-score ≤ -2 standard deviations) in the femur, with 91.4% sensitivity, 52% specificity, and an area under the ROC of 0.831 (p < 0.001). At the lumbar spine, the performance was similar (81.5% sensitivity, 50% specificity, and area under ROC of 0.724; p < 0.001). Regarding the identification of low-impact Fx, the sensitivity was 71%, the specificity was 52%, and the area under the ROC was 0.689 (p < 0.001).

CONCLUSION

The SAPORI is a simple, useful, fast, practice, and valid tool for identifying women at higher risk for low bone density and osteoporotic fractures.

High prevalence of vitamin D deficiency among healthy Saudi Arabian men: relationship to bone mineral density, parathyroid hormone, bone turnover markers, and lifestyle factors

SUMMARY

In this cross-sectional study, the prevalence of vitamin D deficiency [serum 25-hydroxyvitamin D (25(OH)D) <50 nmol/L] was 87.8% among Saudi Arabian men. There was a linear inverse relationship between serum 25(OH)D and intact parathyroid hormone (PTH) levels, but without a threshold of 25(OH)D at which intact PTH values plateaued.

INTRODUCTION

Vitamin D insufficiency and/or deficiency has now reached epidemic proportions and has been linked to low bone mineral density (BMD), some lifestyle factors, and obesity in adults. This relationship is not well documented in Saudi Arabian men. This study examines the relationship between vitamin D status, intact parathyroid hormone (intact PTH), and lifestyle factors among Saudi Arabian men.

METHODS

This cross-sectional study involved 834 men aged 20-74 years living in Jeddah area who were randomly selected and medically examined. Men had their BMD (lumbar spine (L1-L4) and neck femur), 25(OH)D, intact PTH, and other parameters measured according to detailed inclusion criteria.

RESULTS

Deficiency (25(OH)D<50 nmol/L) and insufficiency (≥50-75 nmol/L) were present in 87.8% and 9.7%, respectively. Deficiency was common among older and obese men with no education and sedentary lifestyle sampled during summer and spring. Serum 25(OH)D showed an inverse linear relationship with intact PTH, but there was no threshold of serum 25(OH)D at which PTH levels plateaued. There was a positive correlation between BMD values at both lumbar spine (L1-L4) (P < 0.023) and neck femur (P < 0.036) and serum 25(OH)D levels, respectively.

CONCLUSIONS

Functionally significant vitamin D deficiency affects BMD and bone turnover markers among Saudi Arabian men and is largely attributed to older age, obesity, sedentary lifestyle, no education, poor exposure to sunlight, smoking, and poor dietary vitamin D supplementation. The data suggest that an increase in PTH cannot be used as a marker for vitamin D deficiency.

Influence of age and gender on associations of body mass index with bone mineral density, bone turnover markers and circulating calcium-regulating and bone-active sex hormones

Although it is well known that body mass index (BMI) and bone mineral density (BMD) are positively correlated, the mechanisms by which adiposity reduces the risk of osteoporotic fractures are not fully understood. The present study was initiated to gain deeper insight into the mechanisms underlying the osteoprotective effect of adiposity, and to assess particularly the relevance that BMI-associated changes in circulating hormone levels could have for the build-up of additional bone mineral density. Using data from a previous study on a large cohort of healthy adult Austrians, we analyzed correlations of BMI with (i) BMD at sites in the lumbar spine and hip region, (ii) bone resorption and formation markers, (iii) circulating levels of vitamin D, parathyroid hormone, testosterone and estrogen, and (iv) rates of daily vitamin D and calcium intake. After adjustment for age, positive correlations between BMI and BMD were highly significant (P<0.0001) at all skeletal sites across the entire study cohort. Associations were stronger in post-menopausal women than in pre-menopausal women and in men. In absolute values, the gain in BMD at the lumbar spine from an incremental rise of BMI in post-menopausal women was 1.5-fold higher than in pre-menopausal women, and three times of that observed in men (P<0.05). Inverse relations between BMI and β-crosslaps were consistently found in men (P<0.01) and in women before and after menopause (P<0.01 and P<0.05, respectively), suggesting that inhibition of osteoclastic bone resorption is responsible at least in part for the positive effect of high BMI on BMD. Sub-group analysis revealed that increasing BMI was associated with a significant fall of testosterone in men (P<0.05), and of 25-(OH)D in pre- and post-menopausal women (P<0.001 and P<0.05, respectively), but with a significant rise in PTH (P<0.01) in women before menopause. Since all these hormonal changes would cause bone loss, this excludes their playing any role in the osteoprotective effect of adiposity.

Osteoporotic fractures in the Brazilian community-dwelling elderly: prevalence and risk factors

The risk of osteoporotic fractures is known to vary among populations. There are no studies analyzing concomitantly clinical, densitometric, and lab risk factors in miscigenated community-dwelling population of Brazil. A total of 1007 elderly subjects (600 women and 407 men) from São Paulo, were evaluated using a questionnaire that included risk factors for osteoporotic fractures. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the hip and lumbar spine. Laboratory blood tests were also obtained. The prevalence of osteoporotic fractures was 13.2% (133 subjects), and the main fracture sites were distal forearm (6.0%), humerus (2.3%), femur (1.3%), and ribs (1.1%). Women had a higher prevalence (17.5%; 95% confidence interval [CI]: 14.6-20.6) than men (6.9%; 95% CI: 4.4-9.3) (p<0.001). After adjusting for significant variables, logistic regression revealed that female gender (odds ratio [OR]=2.7; 95% CI; 1.6-4.5; p<0.001), current smoking (OR=1.9; 95% CI: 1.2-3.3; p=0.013), and the femoral neck T-score (OR=0.7; 95% CI: 0.5-0.9; p=0.001) remain significant risk factors for osteoporotic fractures in the community-dwelling elderly. Our findings identified that female gender, current smoking, and low hip BMD are independent risk factors for osteoporotic fractures.

A osteoporose e a mulher envelhecida: fatores de risco

A osteoporose é uma doença silenciosa, o que implica reconhecer os fatores de risco inerentes a cada mulher para se determinar estratégias de melhoria da qualidade de vida. OBJETIVO: verificar a chance de as mulheres terem fatores de risco para osteoporose, através do questionário proposto pelo estudo do European Vertebral Osteoporosis Study Group (EVOS) e avaliar o desempenho nas atividades da vida diária em relação às ações mais executadas no dia a dia pelo questionário Atividades Instrumentais da Vida Diária (AIVD). O exame da densitometria óssea foi realizado para diagnosticar a osteoporose. METODOLOGIA: aplicaram-se a ficha com dados sociodemográficos e o questionário EVOS no primeiro tempo e após o questionário de AIVD e o exame de densitometria óssea nas mulheres na pós-menopausa, com idade = 60 anos. RESULTADOS: foram analisadas 58 mulheres, com idade média de 67,3 anos. O índice de massa corporal (IMC), um dos fatores de risco, foi considerado fator preditor para ausência de osteoporose, pois as mulheres deste estudo apresentavam sobrepeso. Dezesseis (28%) apresentavam osteoporose, com escores médios significativamente menores que aquelas que não têm osteoporose, para os itens: consegue fazer compras (p=0,006), consegue fazer trabalhos manuais (p=0,018) e cuidar das finanças (p=0,014). CONCLUSÃO: a variável IMC na regressão logística teve relevância no questionário EVOS. Na análise do questionário de AIVD, as mulheres com osteoporose apresentam significância em relação às que não tinham osteoporose, para os itens: consegue fazer compras, consegue fazer trabalhos manuais e cuidar das finanças.

Quality of life in postmenopausal women with reduced bone mineral density: psychometric evaluation of the Polish version of QUALEFFO-41

INTRODUCTION

Evaluation of the quality of life of patients with osteoporosis concerns the physical, emotional, social and pain quality of life domains. The aim of the research was to describe the psychometric properties of the Polish version of QUALEFFO-41 in 253 Polish postmenopausal women with osteopenia or osteoporosis and in 132 postmenopausal women with normal BMD.

MATERIAL AND METHODS

The internal reliability of QUALEFFO-41 was studied using Cronbach's alpha coefficient. The reproducibility of the QUALEFFO-41 scales was assessed using Pearson's correlation. The capacity of questions to discriminate between women with reduced bone mineral density (BMD) and normal subjects was assessed by conditional logistic regression to derive an odds ratio with 95% confidence intervals. The discriminative power, which measures the ability of the questionnaire to discriminate between patients, was assessed by clinical validity. Additionally, receiver operating characteristic (ROC) curves were constructed to assess the ability of QUALEFFO-41.

RESULTS

Cronbach's α coefficient reflecting the reliability and repeatability of the instrument for all domains was satisfactory. Results of scores for domains of QUALEFFO-41 and the score for total QUALEFFO-41 demonstrate a significant difference (p < 0.001) among all groups; only in the case of the pain domain was there a significant difference at the level of p < 0.01 between normal subjects and osteoporotic patients. Receiver operating characteristic curve analysis demonstrated a good discriminating capacity of individual domains and total QUALEFFO-41 score.

CONCLUSIONS

The Polish version of QUALEFFO-41 can be used among patients with reduced BMD compared to normal subjects, independently of vertebral fractures, as it is coherent and discriminates well between women with reduced BMD and normal subjects.

Measuring spine fracture outcomes: common scales and checklists

INTRODUCTION

Although outcome instruments have been used extensively in spine surgical research, few studies at present specifically address their use in investigations regarding spine trauma. In this review we provide a summary of the outcome instruments used most frequently in spine trauma research, identify the unique challenges of studying outcomes of spine trauma patients, and propose an integrated approach that may be beneficial for future studies.

METHODS

We reviewed the use of outcome instruments applicable to spine trauma research, including generic health measures, inventories of back-specific function, pain scales, health related quality of life (HRQOL) instruments, and radiographic determinants of outcome.

RESULTS

Several inventories have been utilised to measure clinical outcomes following spinal trauma. Excluding measures of neurological function (e.g. ASIA motor score), none have been specifically validated for use with spine fractures. The SF-36, RMDQ, and ODI are amongst the most commonly used instruments. Importantly, the use of validated functional outcome measures in spine trauma research is hampered by the fact that the pre-morbid state of patients who sustain spine trauma may not be accurately represented by normative values established for the general population. The VAS is used most frequently to assess degree of neck and back pain. Most studies have relied on non-validated measures to determine radiographic results of treatment, although more elegant radiographic metrics exist.

CONCLUSIONS

Functional outcome measurement of traumatically injured spine patients is challenging because available generic and spine-specific instruments were not designed for or validated in this population. Furthermore, no single inventory is capable of capturing global data necessary to evaluate results following these injuries. Investigations seeking to quantify outcomes following spine trauma should consider the use of a combination of existing surveys in a complementary fashion that should include a generic health survey, a measure of back-specific function, and determinants of bodily pain and work-related disability.

Prevalence and risk factors of radiographic vertebral fracture in Brazilian community-dwelling elderly

The prevalence and risk factors of radiographic vertebral fracture were determined among Brazilian community-dwelling elderly. Vertebral fractures were a common condition in this elderly population, and lower hip bone mineral density was a significant risk factor for vertebral fractures in both genders.

INTRODUCTION

The aim of the study was to estimate the prevalence of radiographic vertebral fracture and investigate factors associated with this condition in Brazilian community-dwelling elderly.

METHODS

This cross-sectional study included 943 elderly subjects (561 women and 382 men) living in São Paulo, Brazil. Thoracic and lumbar spine radiographs were obtained, and vertebral fractures were evaluated using Genant's semiquantitative method. Bone mineral density (BMD) was measured by dual X-ray absorptiometry, and bone biochemical markers were also evaluated. Female and male subjects were analyzed independently, and each gender was divided into two groups based on whether vertebral fractures were present.

RESULTS

The prevalence of vertebral fracture was 27.5% (95% CI 23.8-31.1) in women and 31.8% in men (95% CI 27.1-36.5) (P = 0.116). Cox regression analyses using variables that were significant in the univariate analysis showed that age (prevalence ratio = 1.03, 95% CI 1.01-1.06; p = 0.019) and total femur BMD (PR = 0.27, 95% CI 0.08-0.98; p = 0.048) were independent factors in predicting vertebral fracture for the female group. In the male group, Cox regression analyses demonstrated that femoral neck BMD (PR = 0.26, 95% CI 0.07-0.98; p = 0.046) was an independent parameter in predicting vertebral fractures.

CONCLUSIONS

Our results suggest that radiographic vertebral fractures are common in Brazilian community-dwelling elderly and that a low hip BMD was an important risk factor for this condition in both genders. Age was also significantly correlated with the presence of vertebral fractures in women.

Risk factors for osteoporotic fractures and low bone density in pre and postmenopausal women

OBJECTIVE

To estimate the prevalence and analyze risk factors associated to osteoporosis and low-trauma fracture in women.

METHODS

Cross-sectional study including a total of 4,332 women older than 40 attending primary care services in the Greater São Paulo, Southeastern Brazil, between 2004 and 2007. Anthropometrical and gynecological data and information about lifestyle habits, previous fracture, medical history, food intake and physical activity were obtained through individual quantitative interviews. Low-trauma fracture was defined as that resulting from a fall from standing height or less in individuals 50 years or older. Multiple logistic regression models were designed having osteoporotic fracture and bone mineral density (BMD) as the dependent variables and all other parameters as the independent ones. The significance level was set at p<0.05.

RESULTS

The prevalence of osteoporosis and osteoporotic fractures was 33% and 11.5%, respectively. The main risk factors associated with low bone mass were age (OR=1.07; 95% CI: 1.06;1.08), time since menopause (OR=2.16; 95% CI: 1.49;3.14), previous fracture (OR=2.62; 95% CI: 2.08;3.29) and current smoking (OR=1.45; 95% CI: 1.13;1.85). BMI (OR=0.88; 95% CI: 0.86;0.89), regular physical activity (OR=0.78; 95% CI: 0.65;0.94) and hormone replacement therapy (OR=0.43; 95% CI: 0.33;0.56) had a protective effect on bone mass. Risk factors significantly associated with osteoporotic fractures were age (OR=1.05; 95% CI: 1.04;1.06), time since menopause (OR=4.12; 95% CI: 1.79;9.48), familial history of hip fracture (OR=3.59; 95% CI: 2.88;4.47) and low BMD (OR=2.28; 95% CI: 1.85;2.82).

CONCLUSIONS

Advanced age, menopause, low-trauma fracture and current smoking are major risk factors associated with low BMD and osteoporotic fracture. The clinical use of these parameters to identify women at higher risk for fractures might be a reasonable strategy to improve the management of osteoporosis.

Risk factors for osteoporosis in healthy males

We investigated the correlation of bone mineral density (BMD) with risk factors and laboratory parameters (e.g., markers of bone turnover, biochemical indicators, and hormonal factors) in males without secondary osteoporosis. A total of 105 males were divided into two groups: Group 1 (n: 52) <60 years, and Group 2 (n:53) ≥ 60 years. The subjects were evaluated for risk factors (European Vertebral Osteoporosis Study (EVOS) and BMD) and for biochemical (i.e., blood calcium, blood phosphorus, urinary calcium/phosphorus, creatinine clearance, osteocalcin, and deoxypyridinoline) and hormonal markers (follicle-stimulating hormone [FSH], luteinizing hormone [LH], free testosterone [fT], and parathyroid [PTH]) of bone mineral metabolism. In Group 1, no significant relationship was observed between risk factors for both lumbar and femoral neck BMDs and risk factors and laboratory parameters (p>0.05). On the other hand, we observed in Group 2 a significant positive correlation between lumbar BMD and BMI, BMI at 25 years of age, and fT; in the same group, a negative correlation between lumbar BMD and deoxypyridinoline (p<0.05) was seen. We saw a significant positive correlation between femoral neck BMD and BMI, BMI at 25 years of age, and daily activities of life in Group 2. In addition, we saw a negative correlation between femoral neck BMD and height difference, fT, LH, and deoxypyridinoline in Group 2 (p<0.05). Risk factors for male osteoporosis were multifactorial: demographic and clinical data (difference of height, BMI, physical activity) together with biochemical and hormonal data (deoxypyridinoline, fT, LH) were significant, and most of the risk factors analyzed were related to bone loss in the proximal femur.

Reference intervals of biochemical bone turnover markers for Saudi Arabian women: a cross-sectional study

Biochemical bone turnover markers (BTMs) provide important information on the diagnosis, therapy and monitoring of metabolic bone diseases including osteoporosis. One goal of antiresorptive therapy in women is to decrease biochemical BTMs to the lower half of reference intervals for healthy pre-menopausal counterparts, using newly developed automated assays of such markers. The main objectives of the present study were to: (1) establish reference interval values for the following biochemical BTMs: serum osteocalcine (s-OC), bone alkaline phosphatase (s-bone ALP), procollagen type 1 N-terminal propeptide (s-PINP), crosslinked C-terminal telopeptide of Type 1 collagen (s-CTX), tartarate-resistant acid phosphatase isoform 5b (s-TRACP-5b) and urinary: CTX (u-CTX), N-telopeptides of type 1 collagen (u-NTX), pyridinoline (u-PYD) and deoxypyridinoline (u-DPD) in randomly selected Saudi healthy pre-menopausal women; (2) study the changes in biochemical BTMs in relation to age in pre- and post-menopausal women and the factors reported to influence bone turnover and (3) determine the effect of menopausal status on BTMs. A total of 2125 women were studied [including (n=1557) pre-, and (n=568) post-menopausal women, respectively, aged 20-79 years]. A total of 765 healthy pre-menopausal women (aged 35-45 years) were used to establish reference intervals for biochemical BTMs. All women studied were medically examined and had their bone mineral density (BMD) values obtained for the lumbar spine (L(1)-L(4)) and femoral neck according to detailed inclusion criteria. In all women, values of biochemical BTMs, decreased with increasing age up to the age of 45 years, increased steeply among women in their 50s and remained increased in post-menopausal women. Significant increases were evident in all biochemical BTMs in post-menopausal women with >5 years since menopause with the exception of s-OC, u-DPD, and u-PYD. Using stepwise multiple linear regression analysis, several variables were identified (depending on the BTM) as determinants of BTMs including age, BMI, parity, FSH, LH, PTH, s-Ca, s-Mg, s-PO(4) and 25(OH)D. In the reference intervals group, there are no significant correlations between any of the biochemical BTMs and age of menarche, day of menstrual cycle, physical activity, total daily dietary calcium and caffeine intakes and parity. It is recommended that the age range 35-45 years should be used when establishing biochemical BTMs reference intervals in Saudi Arabian pre-menopausal women.

Thyroid function within the upper normal range is associated with reduced bone mineral density and an increased risk of nonvertebral fractures in healthy euthyroid postmenopausal women

CONTEXT

The relationship between thyroid function and bone mineral density (BMD) is controversial. Existing studies are conflicting and confounded by differences in study design, small patient numbers, and sparse prospective data.

OBJECTIVE

We hypothesized that variation across the normal range of thyroid status in healthy postmenopausal women is associated with differences in BMD and fracture susceptibility.

DESIGN

The Osteoporosis and Ultrasound Study (OPUS) is a 6-yr prospective study of fracture-related factors.

SETTING

We studied a population-based cohort from five European cities.

PARTICIPANTS

A total of 2374 postmenopausal women participated. Subjects with thyroid disease and nonthyroidal illness and those receiving drugs affecting thyroid status or bone metabolism were excluded, leaving a study population of 1278 healthy euthyroid postmenopausal women.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

We measured free T(4) (fT4) (picomoles/liter), free T(3) (fT3) (picomoles/liter), TSH (milliunits/liter), bone turnover markers, BMD, and vertebral, hip, and nonvertebral fractures.

RESULTS

Higher fT4 (beta = -0.091; P = 0.004) and fT3 (beta = -0.087; P = 0.005) were associated with lower BMD at the hip, and higher fT4 was associated with increasing bone loss at the hip (beta = -0.09; P = 0.015). After adjustment for age, body mass index, and BMD, the risk of nonvertebral fracture was increased by 20% (P = 0.002) and 33% (P = 0.006) in women with higher fT4 or fT3, respectively, whereas higher TSH was protective and the risk was reduced by 35% (P = 0.028). There were independent associations between fT3 and pulse rate (beta = 0.080; P = 0.006), increased grip strength (beta = 0.171; P<0.001), and better balance (beta = 0.099; P < 0.001), indicating that the relationship between thyroid status and fracture risk is complex.

CONCLUSIONS

Physiological variation in normal thyroid status is related to BMD and nonvertebral fracture.

Vitamin D deficiency and high serum levels of vitamin A increase the risk of osteoporosis evaluated by Quantitative Ultrasound Measurements (QUS) in postmenopausal Spanish women

OBJECTIVES

Association between vitamin D deficiency and excess of vitamin A as a potential risk factor of osteoporosis and fracture has been evaluated.

DESIGN AND METHODS

232 healthy postmenopausal women were studied. Serum parameters were analyzed by standard methods and fat-soluble vitamins by an own HPLC method. QUS measurement of the calcaneal bone was carried out by Sahara.

RESULTS

124 patients were considered non-osteoporotic and 101 (44.9%) were osteoporotic. The prevalence of high serum levels of retinol was 36.4% and vitamin D deficiency was 70.1%. 60.4% of women with vitamin D deficiency have high serum levels of retinol. In the whole population, the increased risk of osteoporosis was up to three times higher for the highest retinol quintile, as compared with the lowest retinol quintile. Whereas in women with vitamin D deficiency the risk of osteoporosis increased was up 5 times higher than women in the lowest quintile of retinol.

CONCLUSIONS

Our results show that high retinol levels together with vitamin D deficiency are hitherto an overlooked risk factor for osteoporosis.

Increase in vertebral fracture risk in postmenopausal women using omeprazole

Proton pump inhibitors are taken by millions of patients for prevention and treatment of gastroesophageal diseases. Case-control studies have suggested that use of omeprazole is associated with an increased risk of hip fractures. The aim of this prospective study was to assess the risk of vertebral fractures in postmenopausal women using omeprazole. We studied 1,211 postmenopausal women enrolled in the Osteoporosis and Ultrasound Study from the general population. Information on omeprazole and other risk factors for fractures including prevalent fractures and bone mineral density was obtained at baseline. Vertebral fractures were assessed on X-rays obtained at baseline and at the end of the 6-year follow-up and analyzed centrally. At baseline, 5% of this population was using omeprazole. Age-adjusted rates for vertebral fractures were 1.89 and 0.60 for 100 person-years for omeprazole users and nonusers, respectively (P = 0.009). In the multivariate analysis, omeprazole use was a significant and independent predictor of vertebral fractures (RR = 3.50, 95% CI 1.14-8.44). The other predictors were age higher than 65 years (RR = 2.34, 95% CI 1.02-5.34), prevalent vertebral fractures (RR = 3.62, 95% CI 1.63-8.08), and lumbar spine T score </= -2.5 (RR = 2.38, 95% CI 1.03-5.49). Omeprazole use is associated with an increased risk of vertebral fractures in postmenopausal women. Further studies are required to determine the mechanism of the association between the underlying gastric disease, omeprazole use, and risk of osteoporotic fractures.

Postmenopausal Canarian women receiving oral glucocorticoids have an increased prevalence of vertebral fractures and low values of bone mineral density measured by quantitative computer tomography and dual X-ray absorptiometry, without significant changes in parathyroid hormone

BACKGROUND

Daily doses higher than 7.5 mg/daily of prednisone or equivalents confer a great risk of vertebral and hip fractures with a clear dose dependence of fracture risk. Information regarding the utility in assessing trabecular bone mineral density by quantitative computer tomography (QCT) in these patients, either in the Canaries or in Spain, is lacking. Moreover, in this setting, the importance of secondary hyperparathyroidism is still controversial.

DESIGN, PATIENTS AND METHODS

Cross-sectional observational study performed on 1177 consecutive Canary postmenopausal women who attended our Bone Metabolic Unit. The Patient Group was composed of 88 postmenopausal women who were taking oral corticosteroids in dose higher than 7.5 mg/day of prednisone or equivalent for more than 6 months (OG group). The Control Group included 838 postmenopausal women who did not take steroids. A complete validated questionnaire for osteoporosis risk assessment and a complete physical examination were performed. A lateral X-ray of the spine was performed on every woman. Bone mineral density (BMD) was measured at the lumbar spine (LS) by dual X-ray Absorptiometry (DXA) and QCT and at the femoral neck by DXA. Fasting serum and 24 hour urine was collected and biochemical markers of bone remodelling were studied.

RESULTS

Both groups were comparable in general characteristics and calcium intake. The OG group showed lower values of BMD estimated both by DXA and QCT (p<0.05). LS BMD was closely correlated by using both methods (r=0.636, p<0.001). The OG group showed lower values of osteocalcin (p=0.023) and TRAP (p=0.026) without significant differences in PTH. Patients in OG group had a higher prevalence of vertebral fractures than controls (13.3% vs 8.6%; crude values: p=0.049, OR: 1.63 (0.99-2.67); age adjusted: p=0.003, OR 2.29 (1.33-9.93)).

CONCLUSIONS

In postmenopausal Canarian women, chronic glucocorticoid therapy is associated with low bone mineral density, measured either by DXA or QCT, with evidence of low turnover and high prevalence of fractures without significant changes in PTH. DXA and QCT provide similar information in the assessment of this high risk population.

Risk factors for vertebral and nonvertebral fracture over 10 years: a population-based study in women

Risk factors may vary for different types of fracture, in particular for vertebral fractures. We followed 367 women >50 yr of age from a population-based cohort for up to 10 yr. Factors that predicted vertebral rather than nonvertebral fractures related to physical weakness, poor health, and weight loss. Similar factors were also associated with greater bone loss at the hip.

INTRODUCTION

Many risk factors predict fractures overall, but it is less clear whether certain factors relate to vertebral fractures in particular. The aim of this study was to compare the risk factors for vertebral and nonvertebral fractures.

MATERIALS AND METHODS

We carried out a 10-yr prospective population-based study of 375 women who were 50-85 yr of age initially. At baseline, we measured BMD, blood and urine biochemistry, and anthropometric measurements. Medical and lifestyle data were obtained by questionnaire. Incident vertebral fractures were determined for 311 subjects from spinal radiographs at 0, 2, 5, 7, and 10 yr using an algorithm-based qualitative method, and nonvertebral fractures were confirmed radiographically. Relative risks were calculated by Cox regression analysis.

RESULTS

During follow-up, 70 subjects sustained one or more nonvertebral fractures and 29 sustained one or more vertebral fractures. Risk factors that predicted both types of fracture included increasing age, decreasing BMD at all sites, prevalent vertebral fracture, and shorter estrogen exposure. For nonvertebral fractures only, the risk factors included low urinary creatinine and less frequent use of stairs. The factors for vertebral fractures included lighter weight, reduced body fat, heavy smoking, lower serum calcium, albumin, and thyroid T(3), weak grip strength, and poor physical capability. In a multivariate model, weight, fat mass, serum calcium and T(3), prevalent vertebral fracture, and physical capability remained significant. Furthermore, grip strength, serum albumin, weight loss, and physical capability were associated with rate of bone loss at the femoral neck, and a fast rate of bone loss was also associated with vertebral fractures.

CONCLUSIONS

We conclude that overall frailty, which may consist of general poor health, small or thin body size, and lack of strength and physical capability, predicts vertebral fractures but is not a significant predictor of nonvertebral fractures. Bone loss rates are associated with similar risk factors and also with the incidence of vertebral fractures.

Geographic and other determinants of BMD change in European men and women at the hip and spine. a population-based study from the Network in Europe for Male Osteoporosis (NEMO)

INTRODUCTION

While the determinants of BMD change have been studied in women, there have been few longitudinal studies in men. As part of the Network in Europe for Male Osteoporosis (NEMO) study, data were analysed from 1337 men and 1722 women aged 50-86y (mean=67 years) from 13 centres across Europe to assess determinants of BMD change and between-gender contrasts.

METHODS

BMD was measured at the femoral neck, trochanter and/or L2-L4 spine on 2 occasions 0.8-8 years apart (mean=3.5 years) using DXA densitometers manufactured by Hologic (n=6), Lunar (n=5) and Norland (n=2). Each was cross-calibrated using the European Spine Phantom and annual rates of BMD change (g/cm(2)/year) were calculated from the standardised paired BMD values. The EPOS risk factor questionnaire was administered at baseline.

RESULTS

In multivariate linear regression models, there were large between centre differences in the mean rates of BMD change in all 3 sites for both genders (P<0.0001) with the standard deviation of the between centre heterogeneity in the adjusted means being 0.005 g/cm(2)/year at the femoral neck. The overall adjusted mean annual rates of BMD change in g/cm(2)/year (95% CI) pooled across centres by random effects meta-analysis in men were: femoral neck -0.005 (-0.009, -0.001); trochanter -0.003 (-0.006, -0.001); and spine 0.000 (-0.004, 0.004). In women the respective estimates were: -0.007 (-0.009, -0.005); -0.004 (-0.006, -0.003); and -0.005 (-0.008, -0.001). The I(2) statistic for heterogeneity was between 81% and 94%, indicating strong evidence of between centre heterogeneity. Higher baseline BMD value was associated with subsequent greater decline in BMD (P<0.001). Preserved BMD was associated with higher baseline body weight in all 3 sites in men (P<0.012) but not in women. Weight gain preserved BMD (P<0.039) in all 3 sites for both genders, except the male spine. Increasing age was associated with faster BMD decline at the trochanter in both genders (P<0.026) and with a slower rate of decline at the female spine (P=0.002). Effects of lifestyle, physical activity, medications, and reproductive factors were not consistent across sites or between genders.

CONCLUSION

These results show major geographic variations in rates of BMD change in men and women over 50 years of age across diverse European populations and demonstrate that body weight and weight gain are key determinants of BMD change in men.

Effects of physical activity on evolution of proximal femur structure in a younger elderly population

INTRODUCTION

For a fixed weight, a wider bone of standardised length is stiffer. But moving the cortices away from the centre of mass risks creating structural (elastic) instability, and hip fractures have been postulated to occur as a consequence of buckling of the thinned supero-lateral femoral neck cortex during a fall. We hypothesised that stereotyped physical activity (e.g., walking) may help conserve bending resistance (section modulus, Z) through redistribution of bone tissue, but it might be at the expense of supero-lateral cortical stability.

METHODS

Hip structural analysis (HSA) software applied to DXA scans was used to derive measurements of section modulus and distances of a cross-section's centre of mass from the supero-lateral cortical margin (lateral distance, in cm). DXA scans were obtained on 1361 men and women in the EPIC-Norfolk population-based prospective cohort study. Up to 4 repeat DXA scans were done in 8 years of follow-up. Weight, height and activities of daily living were assessed on each occasion. A detailed physical activity and lifestyle questionnaire was administered at baseline. The lateral distance was measured on three narrow cross-sections with good precision: narrow neck (NN, coefficient of variation 2.6%), intertrochanter (IT) and shaft (S). A linear mixed model was used to assess associations with predictors.

RESULTS

Ageing was associated with medial shifting of the centre of mass, so that lateral distance increased. Both greater weight and height were associated with greater lateral distance (P<0.0001). Among physical activity-related variables, walking/cycling for >1 h/day (P=0.025), weekly time spent on moderate impact activity (P=0.003), forced expiratory volume in 1 s (NN and IT, P<0.026) and lifetime physical activity (IT, P<0.0001) were associated with higher lateral distance. However, after adjusting for these variables, activities of daily living scores (NN, P<0.0001) and weekly time spent on low impact hip flexing activities were associated with shorter lateral distance (P=0.001). Greater baseline lateral distance was significantly associated with increased risk of subsequent hip fracture (n=26) in females (P<0.05, all regions) independently of age, height and bone mineral content.

CONCLUSION

The age-related shift medially of the centre of mass of the femoral neck and trochanter may have adverse effects on fracture resistance in the event of a fall, so compromising the beneficial effects of walking on fitness, strength and risk of falling. The role of more diverse physical activity patterns in old age that impose loading on the supero-lateral cortex of the femur, involving for example hip flexion and stretching, needs investigation for their ability to correct this medial shifting of the centre of mass.

Collagen type 1 (COL1A1) Sp1 binding site polymorphism is associated with osteoporotic fractures but not with bone density in post-menopausal women from the Canary Islands: a preliminary study

BACKGROUND AND AIMS

An association between the polymorphism for transcription factor Sp1 in the gene COL1A1 and low bone density (BMD) and osteoporotic fractures has been described but not confirmed for all races and ages. The aim of this preliminary work was to ascertain whether this association is present in women from the Canary Islands.

METHODS

Polymerase chain reaction RFLP was used to determine COL1A1 polymorphism Sp1 in 199 consecutive outpatient post-menopausal Caucasian women from the Canary Islands, aged 50-70 years. BMD was measured at lumbar spine and hip by DXA and at third lumbar vertebrae by QCT. Prevalent vertebral fractures were recorded on standard lateral X-ray film. Non-vertebral osteoporotic fractures were registered by medical record and self-reported history. Biochemical markers (serum osteocalcin, tartrate-resistant acid phosphatase), blood calcium and phosphate were also assessed.

RESULTS

Distribution genotypes were 113 (50.8%) GG homozygotes, 73 (36.7%) Ss heterozygotes and 7 (3.5%) TT homozygotes. All patients with osteoporotic fractures carried the GG allele more frequently than TT homozygotic women. The odds ratio was 3.01 (95% CI 1.6-5.7) for prevalent vertebral fractures (n=62) and 2.33 (95% CI 1.2-4.4) for all osteoporotic fractures (n=65) for the T-carrying allele vs TT homozygotic women. There was no difference in BMD measured by DXA or QCT, nor in bone markers, blood calcium or phosphate.

CONCLUSIONS

This preliminary study confirmed that the presence of at least one copy of the T allele is associated with osteoporotic fractures, but not with low BMD, in women from the Canary Islands.

Relationship between risk factors and QUS in a European Population: The OPUS study

There are many risk factors associated with low bone mineral density. Quantitative ultrasound (QUS) is a generally accepted method for measurement of bone and has been shown to be strongly associated with future fracture risk. The Osteoporosis and Ultrasound Study (OPUS) is a multi-centre European wide study examining 5 different QUS scanners (4 calcaneal, 1 finger device). The aim of this paper was to examine the relationship between risk factors (as assessed by questionnaire) and QUS measurements. 449 younger women (aged 20 to 39 years) and 2283 older women (aged 55 to 79 years) were included in this analysis. As expected, those with a self-reported previous fracture had lower QUS measurements than those without (P < 0.001). However, no significant difference was seen between those reporting a maternal hip fracture and those who did not report such an event. Differences were found for smokers vs. non-smokers for SOS but not for BUA measurements. Weight was positively correlated with all BUA variables but only with some SOS variables. We determined which risk factors were most strongly associated with QUS measurements by using step-wise multiple regression. Models for each QUS measurement were calculated, and the R2 values ranged from 0.18 to 0.28 for SOS, 0.27 to 0.32 for BUA and 0.31 to 0.42 for the finger QUS device. The most common risk factors across all models were age, use of hormone replacement therapy, self-reported previous fracture, self-reported diagnosis of osteoporosis, current weight, pulse rate and self-reported estimated height at age 20 years. We analysed relationships across the 5 centres and detected some geographical differences in the prevalence of the risk factors. In conclusion, similar relationships are seen with QUS measurements as are found for bone mineral density. However, the strength of the association is dependent on the type of QUS device and variable measured.

Whom to treat? The contribution of vertebral X-rays to risk-based algorithms for fracture prediction. Results from the European Prospective Osteoporosis Study

INTRODUCTION

Vertebral fracture is a strong risk factor for future spine and hip fractures; yet recent data suggest that only 5-20% of subjects with a spine fracture are identified in primary care. We aimed to develop easily applicable algorithms predicting a high risk of future spine fracture in men and women over 50 years of age.

METHODS

Data was analysed from 5,561 men and women aged 50+ years participating in the European Prospective Osteoporosis Study (EPOS). Lateral thoracic and lumbar spine radiographs were taken at baseline and at an average of 3.8 years later. These were evaluated by an experienced radiologist. The risk of a new (incident) vertebral fracture was modelled as a function of age, number of prevalent vertebral fractures, height loss, sex and other fracture history reported by the subject, including limb fractures occurring between X-rays. Receiver Operating Characteristic (ROC) curves were used to compare the predictive ability of models.

RESULTS

In a negative binomial regression model without baseline X-ray data, the risk of incident vertebral fracture significantly increased with age [RR 1.74, 95% CI (1.44, 2.10) per decade], height loss [1.08 (1.04, 1.12) per cm decrease], female sex [1.48 (1.05, 2.09)], and recalled fracture history; [1.65 (1.15, 2.38) to 3.03 (1.66, 5.54)] according to fracture site. Baseline radiological assessment of prevalent vertebral fracture significantly improved the areas subtended by ROC curves from 0.71 (0.67, 0.74) to 0.74 (0.70, 0.77) P=0.013 for predicting 1+ incident fracture; and from 0.74 (0.67, 0.81) to 0.83 (0.76, 0.90) P=0.001 for 2+ incident fractures. Age, sex and height loss remained independently predictive. The relative risk of a new vertebral fracture increased with the number of prevalent vertebral fractures present from 3.08 (2.10, 4.52) for 1 fracture to 9.36 (5.72, 15.32) for 3+. At a specificity of 90%, the model including X-ray data improved the sensitivity for predicting 2+ and 1+ incident fractures by 6 and 4 fold respectively compared with random guessing. At 75% specificity the improvements were 3.2 and 2.4 fold respectively. With the modelling restricted to the subjects who had BMD measurements (n=2,409), the AUC for predicting 1+ vs. 0 incident vertebral fractures improved from 0.72 (0.66, 0.79) to 0.76 (0.71, 0.82) upon adding femoral neck BMD (P=0.010).

CONCLUSION

We conclude that for those with existing vertebral fractures, an accurately read spine X-ray will form a central component in future algorithms for targeting treatment, especially to the most vulnerable. The sensitivity of this approach to identifying vertebral fracture cases requiring anti-osteoporosis treatment, even when X-rays are ordered highly selectively, exceeds by a large margin the current standard of practice as recorded anywhere in the world.

Factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis: a cross-sectional survey

OBJECTIVE

To determine the factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis.

DESIGN

Cross-sectional survey.

SETTING

National survey in the UK.

PARTICIPANTS

Participants were recruited through the National Osteoporosis Society and advertisements in the press and on the radio and included 533 women over age 50 with osteoporosis who were currently taking or had taken bisphosphonate therapy within the previous 12 months.

MAIN OUTCOME MEASURES

Self-reported factors influencing adherence and persistence to bisphosphonate therapy in osteoporosis: fracture history, pain, practical difficulties taking medication (frequency of dosing, dealing with comedications, impact on daily routine), perceptions of therapy, and concerns about bisphosphonate therapy.

RESULTS

Adherence to bisphosphonate therapy was 48% and was associated with previous fracture [odds ratio (OR) 1.62, 95% confidence interval (CI) 1.14-3.02], concerns about medication (OR 1.49, 95% CI 1.01-2.20), and less dissatisfaction with medication (OR 0.65, 95% CI 0.44-0.97). Nonpersistence was associated with dissatisfaction with medication (hazard ratio (HR) 1.83, 95% CI 1.38-2.43), side effects (HR 3.69, 95% CI 2.74-4.97), and concerns about bisphosphonate therapy (HR 2.21, 95% CI 1.48-3.30). For both daily (HR 1.53, 95% CI 1.1-2.33) and weekly bisphosphonates (HR 1.90, 95% CI 1.17-3.07), practical difficulties taking bisphosphonate medication-in particular, too frequent dosing-were associated with nonpersistence.

CONCLUSIONS

Self-reported nonadherence to daily and weekly bisphosphonates is independent of the decision to stop taking treatment (nonpersistence). Nonpersistence is associated with side effects and other factors that could be modified in clinical practice through education, information, and concordant partnerships.

Device-specific thresholds to diagnose osteoporosis at the proximal femur: an approach to interpreting peripheral bone measurements in clinical practice

INTRODUCTION

A single T score criterion cannot be universally applied to different peripheral bone measurement devices, since measurements in an identical population result in a tenfold difference in the prevalence of osteoporosis. The use of peripheral devices is increasing in clinical practice, despite the difficulties in interpreting results. We propose the use of two thresholds, which have either 95% sensitivity or 95% specificity, to identify (1) individuals who require treatment or (2) individuals who require no treatment, both based on a peripheral measurement alone, or (3) individuals who require additional central densitometry measurements.

METHODS

We recruited 500 postmenopausal women, 100 premenopausal women and 279 women with proximal femoral, vertebral, distal forearm or proximal humeral fractures. All subjects underwent dual energy X-ray absorptiometry (DXA) measurements of the lumbar spine, total hip and distal forearm, quantitative computed tomography (QCT) of the distal forearm and quantitative ultrasound (QUS) of the heel (four devices), finger (two devices), radius and metatarsal. We identified the threshold for each device that identified women without osteoporosis with the same sensitivity (upper threshold set at 95%) as total hip DXA and women with osteoporosis with the same specificity (lower threshold set at 95%) as total hip DXA. Individuals between the two thresholds required additional examination by central densitometry.

RESULTS

The correlation between devices varied from 0.173 (QUS finger) to 0.686 (DXA forearm) compared with total hip DXA (P<0.0001). The area under the curve (AUC) between devices varied from 0.604 (QUS finger) to 0.896 (DXA forearm) compared with total hip DXA (P<0.0001). In a population-based cohort (prevalence of osteoporosis 9.8%) the threshold approach appropriately identified between 26% (QUS heel) and 68% (DXA forearm) of subjects in whom a treatment decision could be made without additional central DXA with 95% certainty. In a fracture cohort (prevalence of osteoporosis 36%) between 16% (QUS finger) and 37% (QCT forearm) of subjects were appropriately identified.

CONCLUSION

The threshold approach to interpreting peripheral bone measurements enables a substantial number of individuals with either normal bone mineral density (BMD) or osteoporosis to be selected and treated appropriately.

Reduction of pain and fracture incidence after kyphoplasty: 1-year outcomes of a prospective controlled trial of patients with primary osteoporosis

Previously, we reported significantly reduced pain and improved mobility persisting for 6 months after kyphoplasty of chronically painful osteoporotic vertebral fractures in the first prospective controlled trial. Since improvement of spinal biomechanics by restoration of vertebral morphology may affect the incidence of fracture, long-term clinical benefit and thereby cost-effectiveness, here we extend our previous work to assess occurrence of new vertebral fractures and clinical parameters 1 year after kyphoplasty compared with a conservatively treated control group. Sixty patients with osteoporotic vertebral fractures due to primary osteoporosis were included: 40 patients were treated with kyphoplasty, 20 served as controls. All patients received standard medical treatment. Morphological characteristics, new vertebral fractures, pain (visual analog scale), physical function [European Vertebral Osteoporosis Study (EVOS) score] (range 0-100 each) and back-pain-related doctors' visits were re-assessed 12 months after kyphoplasty. There were significantly fewer patients with new vertebral fractures of the thoracic and lumbar spine, after 12-months, in the kyphoplasty group than in the control group (P=0.0084). Pain scores improved from 26.2 to 44.4 in the kyphoplasty group and changed from 33.6 to 34.3 in the control group (P=0.008). Kyphoplasty treated patients required a mean of 5.3 back-pain-related doctors' visits per patient compared with 11.6 in the control group during 12 months follow-up (P=0.006). Kyphoplasty as an addition to medical treatment and when performed in appropriately selected patients by an interdisciplinary team persistently improves pain and reduces occurrence of new vertebral fractures and healthcare utilization for at least 12 months in individuals with primary osteoporosis.

The discriminative ability of peripheral and axial bone measurements to identify proximal femoral, vertebral, distal forearm and proximal humeral fractures: a case control study

Previous studies evaluating peripheral bone measurement devices have often used discontinued technologies, compared single devices, only evaluated a single fracture syndrome or failed to make a comparison with central densitometry, which is currently the gold standard for fracture discrimination. We have used a case control study to evaluate the ability of different peripheral and central bone techniques to discriminate between fracture cases and controls, determine the impact of different measurement sites, evaluate the role of measuring the cortical or trabecular envelopes using quantitative computed tomography (QCT) and determine the impact of using combinations of sites and techniques on fracture discrimination. We recruited postmenopausal women with proximal femoral (n=53), vertebral (n=73), distal forearm (n=78) or proximal humeral (n=75) fractures, and 500 population-based women (age 55-80 years). All subjects had measurements of the spine, total hip and distal forearm with dual-energy X-ray absorptiometry (DXA), distal forearm QCT and quantitative ultrasound (QUS) of the heel (four devices), finger (two devices), radius and metatarsal. The association of each device with fracture was expressed as the age-adjusted standardized odds ratios (sOR) per 1-SD decrease of population variance. The association of bone measurements with fracture was site-specific. We found the hip (sOR up to 3.40) and vertebral (sOR up to 4.67) fractures were more closely associated with central bone measurements than upper limb fractures (sOR 1.96 and 2.05). The performance of heel broadband ultrasound attenuation (sOR 2.09-2.41), heel speed of sound (sOR 1.79-2.28) and peripheral BMD (sOR 2.07 and 2.24) was comparable with total hip (sOR 2.46) and lumbar spine DXA (sOR 2.31) in discriminating all types of osteoporotic fracture. In general, measuring cortical or trabecular envelopes did not increase sOR. However, combining different measurement sites or technologies provided additional information, which was independent of total hip BMD. The ability of different bone measurements to discriminate between fracture cases and controls is device- and site-specific, with additional information obtained by combining measurement sites and technologies.

Hypermobility syndrome increases the risk for low bone mass

Few studies on the benign joint hypermobility syndrome suggest a tendency toward osteopenia, but there are conflicting results. We assessed bone mineral density in pre-menopausal women with hypermobility. Twenty-five consecutive Caucasian women diagnosed with benign hypermobility syndrome by Beighton score and 23 age- and sex-matched controls were included in the study. Age, menarch age, number of pregnancies, duration of lactation, physical activity and calcium intake were questioned according to European Vertebral Osteoporosis Study Group (EVOS) form. All subjects were pre-menopausal and none of them were on treatment with any drugs effecting bone metabolism or had any other systemic disease. No statistically significant difference was found for body mass index, menarch age, number of pregnancies, duration of lactation, calcium intake, calcium score and physical activity score between the two groups. Total femoral and trochanteric bone mineral density and t and z scores were significantly lower in hypermobile patients compared to the control group. Ward's triangle and femoral neck z scores were also found to be significantly low in hypermobile patients (p<0.05). Significant negative correlations were found between the Beighton scores and trochanteric BMD, t and z scores (r=-0.29, r=-0.30, and r=-0.32) in hypermobility patients. Low bone mass was more frequently found among subjects with hypermobility (p=0.03). Hypermobility was found to increase the risk for low bone mass by 1.8 times (95% confidence interval 1.01-3.38). Our study suggests that pre-menopausal women with joint hypermobility have lower bone mineral density when compared to the controls and hypermobility increases the risk for low bone mass.

Menstrual and Reproductive Factors and Fracture Risk: The Leisure World Cohort Study

BACKGROUND

Because menopausal estrogen is related to the development of osteoporosis, we investigated the potential associations of the estrogen-related events of menarche, pregnancy, and menopause with fracture risk in a population-based, prospective study of older women.

METHODS

The Leisure World Cohort was established in the early 1980s when residents of a California retirement community, including 8877 women, completed a health survey. Incident fractures of the hip (n = 1220), wrist (n = 463), and spine (n = 613) incurred over two decades were identified from four follow-up questionnaires, hospital discharge records, and (for hip fracture) death certificates. Hazard ratios (HR) adjusted for age and other potential confounders were calculated using proportional hazards regression.

RESULTS

Late age at menarche was associated with decreased hip fracture risk (HR = 0.84, 95% CI 0.72-0.98, for age > or = 14 vs. < or = 12 years) but was unrelated to fractures at other sites. Hip fracture risk was also reduced in women who had been pregnant (HR = 0.83, 95% CI 0.72- 0.95). Women who reported menopause at age 45+ had a lower risk of wrist fracture compared with those with menopause at age < or = 44 (HR = 0.74, 95% CI 0.58-0.95 for ages 45-54; HR = 0.71, 95% CI 0.49-1.04 for ages 55+). Although fracture risks did not differ between ever and never users of menopausal estrogen, recency since last use was related to wrist fractures (HR = 1.09, 95% CI 1.03-1.16 for each 5 years since last years).

CONCLUSIONS

The estrogen-related events of menarche, pregnancy, and menopause were not associated with osteoporotic fracture risk in a consistent manner. Other factors related to these events may be influencing development of osteoporosis and the likelihood of sustaining a fracture in older women.

Osteoporosis case finding in the general practice: phalangeal radiographic absorptiometry with and without risk factors for osteoporosis to select postmenopausal women eligible for lumbar spine and hip densitometry

Mass screening for osteoporosis using DXA measurements at the spine and hip is presently not recommended by health authorities. Instead, risk factor questionnaires and peripheral bone measurements may facilitate the selection of women eligible for axial bone densitometry. The aim of this study was to validate a case finding strategy for postmenopausal women who would benefit most from subsequent DXA measurement by using phalangeal radiographic absorptiometry (RA) alone or in combination with risk factors in a general practice setting. The sensitivity and specificity of this strategy in detecting osteoporosis (T-score < or =2.5 SD at the spine and/or the hip) were compared with those of the current reimbursement criteria for DXA measurements in Switzerland. Four hundred and twenty-three postmenopausal women with one or more risk factors for osteoporosis were recruited by 90 primary care physicians who also performed the phalangeal RA measurements. All women underwent subsequent DXA measurement of the spine and the hip at the Osteoporosis Policlinic of the University Hospital of Berne. They were allocated to one of two groups depending on whether they matched with the Swiss reimbursement conditions for DXA measurement or not. Logistic regression models were used to predict the likelihood of osteoporosis versus "no osteoporosis" and to derive ROC curves for the various strategies. Differences in the areas under the ROC curves (AUC) were tested for significance. In women lacking reimbursement criteria, RA achieved a significantly larger AUC (0.81; 95% CI 0.72-0.89) than the risk factors associated with patients' age, height and weight (0.71; 95% C.I. 0.62-0.80). Furthermore, in this study, RA provided a better sensitivity and specificity in identifying women with underlying osteoporosis than the currently accepted criteria for reimbursement of DXA measurement. In the Swiss environment, RA is a valid case finding tool for patients with risk factors for osteoporosis, especially for those who do not qualify for DXA reimbursement.

Treatment of painful vertebral fractures by kyphoplasty in patients with primary osteoporosis: a prospective nonrandomized controlled study

This study investigates the effects of kyphoplasty on pain and mobility in patients with osteoporosis and painful vertebral fractures compared with conventional medical management.

INTRODUCTION

Pharmacological treatment of patients with primary osteoporosis does not prevent pain and impaired activity of patients with painful vertebral fractures. Therefore, we evaluated the clinical outcome after kyphoplasty in patients with vertebral fractures and associated chronic pain for >12 months.

MATERIALS AND METHODS

Sixty patients with primary osteoporosis and painful vertebral fractures presenting for >12 months were included in this prospective, nonrandomized controlled study. Twenty-four hours before performing kyphoplasty, the patients self-determined their inclusion into the kyphoplasty or control group so that 40 patients were treated with kyphoplasty, whereas 20 served as controls. This study assessed changes in radiomorphology, pain visual analog scale (VAS) score, daily activities (European Vertebral Osteoporosis Study [EVOS] score), number of new vertebral fractures, and health care use. Outcomes were assessed before treatment and at 3 and 6 months of follow-up. All patients received standard medical treatment (1g calcium, 1000 IE vitamin D(3), standard dose of oral aminobisphosphonate, pain medication, physical therapy).

RESULTS

Kyphoplasty increased midline vertebral height of the treated vertebral bodies by 12.1%, whereas in the control group, vertebral height decreased by 8.2% (p = 0.001). Augmentation and internal stabilization by kyphoplasty resulted in a reduction of back pain. VAS pain scores improved in the kyphoplasty group from 26.2 +/- 2 to 44.2 +/- 3.3 (SD; p = 0.007) and in the control group from 33.6 +/- 4.1 to 35.6 +/- 4.1 (not significant), whereas the EVOS score increased in the kyphoplasty group from 43.8 +/- 2.4 to 54.5 +/- 2.7 (p = 0.031) and in the control group from 39.8 +/- 4.5 to 43.8 +/- 4.6 (not significant). The number of back pain-related doctor visits within the 6-month follow-up period decreased significantly after kyphoplasty compared with controls: mean of 3.3 visits/patient in the kyphoplasty group and a mean of 8.6 visits/patient in the control group (p = 0.0147).

CONCLUSIONS

The results of this study show significantly increased vertebral height, reduced pain, and improved mobility in patients after kyphoplasty. Kyphoplasty performed in appropriately selected osteoporotic patients with painful vertebral fractures is a promising addition to current medical treatment.