More than osteoporosis: age-specific issues in bone health

Long-Term Clinical Outcomes After Autologous Hematopoietic Stem Cell Transplantation in 49 Individuals Living With HIV (PLWH) and Affected by High-Risk or Relapsed Lymphoma: A European Experience of Continued Relevance for PLWH

Previous reports have indicated that during the era of combination antiretroviral therapy, the major causes of morbidity and mortality in people living with HIV (PLWH) were not solely linked to HIV-related opportunistic infections but also to cancers that were difficult to manage due to HIV-related immunodeficiency. We investigated whether PLWH who underwent autologous hematopoietic stem cell transplantation (ASCT) for lymphomas experienced significant morbidity over the past thirty years following HIV infection. We conducted a retrospective follow-up study of 49 PLWH over a 10-year period following ASCT. We collected survival data, examined the occurrence of long-term events, assessed CD4 + T-cell immune recovery, and analysed the correlation between immune recovery and the events experienced by these patients. The data confirmed the significant long-term effectiveness of ASCT, with an overall survival rate of 78% at 10 years post-ASCT. Opportunistic infections, which occurred soon after ASCT and were associated with lower CD4 + T-cell counts, were successfully managed. However, lymphoma relapse, secondary malignancies, cardiovascular disease, and bone disease, which developed years after ASCT, were major causes of morbidity and mortality in this population. Our findings highlight the need for the development and validation of specific tests to predict risk and guide effective interventions for metabolic diseases, secondary malignancies, and lymphoma relapses in PLWH treated with ASCT for lymphoma.

Clinical efficacy of zoledronic acid combined with percutaneous kyphoplasty in the prevention and treatment of osteoporotic vertebral compression fracture: A systematic review and meta-analysis

OBJECTIVE:

The aim of this study is to investigate the clinical efficacy of zoledronic acid (ZOL) in the treatment and prevention of osteoporotic vertebral compression fractures (OVCF) after percutaneous kyphoplasty (PKP) for elderly patients.

METHODS:

The PubMed, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, VIP, and Embase were investigated through June 2020. All randomized controlled trials (RCT) involving ZOL injections for OVCF were enrolled. Outcome indicators included the bone mineral density (BMD), Visual Analog Scale (VAS), recompression vertebral fracture (RVF), Oswestry Disability Index (ODI), and bone metabolism (Procollagen type I N-terminal propeptide [PINP] and βcross-linked C-telopeptide of type I collagen [β-CTX]), bone cement leakage. Review Manager 5.3 was used to analyze these indicators.

RESULTS:

In this study, (1).. Eight studies had met the eligibility criteria, a total of 578 participants were involved (285 and 293 in the experimental (ZOL) group and control [no ZOL] group, respectively). (2).. The BMD scores of patients with OVCF in the experimental group were significantly higher than that in the control group (P < .05). The VAS scores were significantly different between the 2 groups at the 6, 12 months follow-up (P < .05). After PKP operation, ZOL injections reduced the rate of RVF (P < .05). In the comparison of ODI scores, the experimental group improved compared with the control group (P < .05). Respectively, the bone metabolism of patients with OVCF after ZOL was better than that of patients in control group (P < .05).

CONCLUSION:

Zoledronic acid had a significant effect on the treatment and prevention of OVCF in elderly osteoporotic patients after PKP. Due to the limited quality and data, more high-quality studies are needed to confirm the results of this meta-analysis.

Short Communication: Low Muscle Mass Is Associated with Osteoporosis in Older Adults Living with HIV

Sarcopenia, age-related low muscle mass and function, is a well-established independent risk factor for bone fracture in the geriatric population but is understudied in older people living with HIV (PLWH). The objective of this cross-sectional study was to investigate in older PLWH the relationship between muscle mass and bone mineral density (BMD). Sedentary PLWH who were ≥50 years of age, receiving antiretroviral therapy, and enrolled in an exercise intervention trial were included. Established definitions for sarcopenia and osteopenia/osteoporosis were applied to muscle mass data and BMD collected by dual-energy X-ray absorptiometry before exercise training. Participants were 93% male and 33% Caucasian race with median age 61 years, and median CD4 lymphocytes 707 cells/μL. The majority (64%) were overweight and obese by body mass index. Appendicular skeletal muscle index (ASMI) correlated with BMD at the femoral neck (r = 0.49, p < .01), total hip (r = 0.54, p < .01), and lumbar spine (r = 0.48, p < .05). Low BMD at the femoral neck was present in 39% (26% osteopenia, 13% osteoporosis). ASMI was lower among those with low BMD compared with normal BMD (p = .02). Low muscle mass measured by ASMI is associated with low BMD in clinically stable older PLWH. Detailed body composition assessment may help guide lifestyle recommendations to prevent bone fractures in older PLWH.

Effect of miR-181a-3p on osteogenic differentiation of human bone marrow-derived mesenchymal stem cells by targeting BMP10

Objective: To explore the regulation relationship between miR-181a-3p and BMP10, and their mechanism of osteogenic differentiation of human bone marrow-derived mesenchymal stem cells (MSCs).Methods: After osteogenic induction of MSCs, the ALP activity was detected by ELISA. The expression of miRNA-181a-3p and BMP10 was detected by RT-qPCR, and the protein levels of BMP10 and osteogenic differentiation marker proteins ALK and RUNX2 were detected by Western blot. The TargetScan online website was used to predict the putative target of miR-181a-3p, and dual luciferase reporter assay was performed to validate the targeting relationship between miR-181a-3p and BMP10.Results: In osteogenic differentiation of MSCs, ALP activity, the level of ALK and RUNX2 was evidently increased (p < .05), and the expression of miR-181a-3p was significantly downregulated (p < .05). Moreover, overexpression of miR-181a-3p obviously decreased the expression of BMP10 (p < .05), miR-181a-3p knockdown increased the expression of BMP10 prominently (p < .05). The transfection of miR-181a-3p mimics resulted in significantly downregulation of ALP activity and RUNX2 protein expression in MSCs (p < .05). In addition, overexpression of BMP10 could reverse the inhibitory effect of miR-181a-3p on osteogenic differentiation (p < .05).Conclusions: In conclusion, we found that miR-181a-3p inhibited osteogenic differentiation of MCSs by targeting BMP10.

Fall History and Associated Factors Among Adults Living With HIV-1 in the Cape Winelands, South Africa: An Exploratory Investigation

Background

People with HIV-1 (PWH) exhibit a high fall incidence and increased fracture risk. As little is known about fall frequency and associated factors in PWH residing in lower-middle-income countries (LMIC), we investigated fall frequency, bone quality, and factors associated with fall history in a South African cohort.

Methods

Fifty PWH without obvious predisposing factors for mobility impairments attending 2 public primary care clinics in the Western Cape region participated. Demographic, clinical, and physical performance data were collected. Falls were assessed retrospectively over 12 months. Mobility and balance were evaluated using a physical performance battery. Bone mineral density was screened using quantitative ultrasound (QUS). Associations between variables and falls grouping were analyzed using chi-square tests, t tests, and Mann-Whitney U tests, and effect sizes (ES) were calculated.

Results

Thirty-four percent of PWH (median age, 36.6 years) reported falling during the past year, and 41.2% of fallers reported multiple falls. Fallers had more mobility problems (P = .013), higher fear of falling (P = .007), higher fracture history (P = .003), worse balance performance (P < .001), higher proportions of detectable viral loads (P = .021), and poorer bone quality (P = .040). Differences were of medium to large ES.

Conclusions

This exploratory study is the first to show that relatively young South African PWH without obvious predisposing factors for gait and balance impairments experience falls. The observed fall-associated factors warrant further research using larger samples and longitudinal designs to ascertain fall predictors within this population.

Chronic Distal Sensory Polyneuropathy Is a Major Contributor to Balance Disturbances in Persons Living With HIV

BACKGROUND

Medical comorbidities accumulate in older persons living with HIV (PLWH), causing disability and reduced quality of life. Sensory neuropathy and polypharmacy may contribute to balance difficulties and falls. The contribution of neuropathy is understudied.

OBJECTIVE

To evaluate the contribution of chronic distal sensory polyneuropathy (cDSPN) to balance disturbances among PLWH.

METHODS

Ambulatory PLWH and HIV- adults (N = 3379) were prospectively studied. All participants underwent a neurologic examination to document objective abnormality diagnostic of cDSPN and reported neuropathy symptoms including pain, paresthesias, and numbness. Participants provided detailed information regarding balance disturbance and falls over the previous 10 years. Balance disturbances were coded as minimal or none and mild-to-moderate. Covariates included age, HIV disease, and treatment characteristics and medications (sedatives, opioids, and antihypertensives).

RESULTS

Eleven percent of participants reported balance disturbances at some time during the last 10 years; the rate in PLWH participants exceeding that for HIV- [odds ratio 2.59, 95% confidence interval: 1.85 to 3.64]. Fifty-two percent met criteria for cDSPN. Balance problems were more common in those with cDSPN [odds ratio = 3.3 (2.6-4.3)]. Adjusting for relevant covariates, balance disturbances attributable to cDSPN were more frequent among HIV+ than HIV- (interaction P = 0.001). Among individuals with cDSPN, older participants were much more likely to report balance disturbances than younger ones.

CONCLUSIONS

cDSPN contributes to balance problems in PLWH. Assessments of cDSPN in older PLWH should be a clinical priority to identify those at risk and to aid in fall prevention and the ensuing consequences, including bone fractures, subdural hematoma, hospital admissions, and fatal injury.

Older HIV-infected adults: complex patients- geriatric syndromes (II)

With the widespread adoption of highly active antiretroviral therapy (HAART), HIV infection starts to be considered one of the many chronic illnesses of advanced age. A growing proportion of the affected patients is presently older than 50. It has been suggested that HIV infection may today represent a model of accelerated and accentuated ageing. The need for a closer collaboration between geriatricians and HIV physicians is being growingly recognised to better address the priorities and needs of HIV patients. The final aim behind the generation of such synergies resides in the design of personalised plans of interventions. These plans should stem from the results of a comprehensive assessment of the individual spanning clinical, environmental, and psychosocial domains. Through the early identification of stressors and risk factors potentially disrupting the homeostatic balance of frail patients (including those living with HIV), it might be possible to protect the "biologically old" (but not necessarily "chronologically old") HIV-infected people from developing detrimental geriatric syndromes. In this article, specific features making the ageing HIV population of special interest for geriatric medicine, and the importance of a multidisciplinary model of care are described. The final objective is to stress how the only way for adequately tackling the multifaceted frailty condition of people with HIV is to implement novel models of care based on the comprehensive geriatric assessment.

Bone Mineral Density Declines Twice as Quickly Among HIV-Infected Women Compared With Men

BACKGROUND

Initial declines in bone mineral density (BMD) after antiretroviral therapy initiation in HIV are well described, but data on long-term changes and risk factors for decline, particularly among women, are limited.

METHODS

HIV-infected men and women in the Modena Metabolic Clinic underwent dual-energy X-ray absorptiometry (DXA) scans every 6-12 months for up to 10 years (median 4.6 years). Mixed effect regression models in combined and sex-stratified models determined annual rates of decline and clinical factors associated with BMD. Models included demographics, HIV-specific factors, and bone-specific factors; a final model added a sex × time interaction term.

RESULTS

A total of 839 women and 1759 men contributed ≥2 DXA scans. The majority (82%) were 50 years and younger; 76% had HIV-1 RNA <50 copies per milliliter at baseline; 15% of women were postmenopausal and 7% of men had hypogonadism; and 30% and 27%, respectively, had hepatitis C virus (HCV) coinfection. The adjusted slopes in BMD among women and men were significantly different at both the femoral neck (women -0.00897 versus men -0.00422 g/cm per year; P < 0.001) and L-spine (women -0.0127 versus men -0.00763 g/cm per year; P < 0.001). Modifiable risks associated with BMD decline included antiretroviral therapy exposure (greater decline with tenofovir disoproxil fumarate and less decline with integrase strand transfer inhibitor therapy), HCV, physical activity, and vitamin D insufficiency.

CONCLUSIONS

Among HIV-infected individuals, bone density at the femoral neck, a significant predictor of fracture risk, declined twice as quickly among women compared with men. Female sex was independently associated with both lower femoral neck and lumbar BMD over time in adjusted models.

Chinese Herbal Medicine for Osteoporosis: A Meta-analysis of Randomized Controlled Trials

Osteoporosis is a major public health problem in the elderly population. Several studies have suggested that Chinese herbal medicine has antiosteoporotic activities that might be beneficial for osteoporosis. This study aimed to assess the effectiveness of Chinese herbal medicine in osteoporosis patients. We comprehensively searched for randomized controlled trials (until December 2016) that compared Chinese herbal medicine with Western medicine in adults with osteoporosis and reported bone mineral densities (BMDs). A total of 10 randomized controlled trials were included. The pooled results suggested that the increased spine BMD was lower but not significant in the Chinese herbal medicine group than in the Western drug group (standard mean difference [SMD] = -0.11, 95% confidence interval [CI]: -0.62 to 0.39, p > 0.05). In the subgroup analysis, in postmenopausal women, Chinese herbal medicine also showed a insignificantly higher increment in BMD than the control group (SMD = 0.22, 95% CI: -0.00 to 0.43, p = 0.05). For different treatment durations, subgroups over 6 mo (SMD = 0.09, 95% CI: -0.24 to 0.41, p > 0.05) and less than 6 mo (SMD = -0.25, 95% CI: -1.14 to 0.64, p > 0.05) showed comparable BMDs between the 2 therapies. Our study demonstrated that Chinese herbal medicine alone did not significantly increase lumbar spine BMD. Further studies with better adherence to the intervention are needed to confirm the results of this meta-analysis.

Objective impairments of gait and balance in adults living with HIV-1 infection: a systematic review and meta-analysis of observational studies

BACKGROUND

Gait and balance deficits are reported in adults with HIV infection and are associated with reduced quality of life. Current research suggests an increased fall-incidence in this population, with fall rates among middle-aged adults with HIV approximating that in seronegative elderly populations. Gait and postural balance rely on a complex interaction of the motor system, sensory control, and cognitive function. However, due to disease progression and complications related to ongoing inflammation, these systems may be compromised in people with HIV. Consequently, locomotor impairments may result that can contribute to higher-than-expected fall rates. The aim of this review was to synthesize the evidence regarding objective gait and balance impairments in adults with HIV, and to emphasize those which could contribute to increased fall risk.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic search of published observational studies was conducted in March 2016. Methodological quality was assessed using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Narrative synthesis of gait and balance outcomes was performed, and meta-analyses where possible.

RESULTS

Seventeen studies were included, with fair to low methodological quality. All studies used clinical tests for gait-assessment. Gait outcomes assessed were speed, initiation-time and cadence. No studies assessed kinetics or kinematics. Balance was assessed using both instrumented and clinical tests. Outcomes were mainly related to center of pressure, postural reflex latencies, and timed clinical tests. There is some agreement that adults with HIV walk slower and have increased center of pressure excursions and -long loop postural reflex latencies, particularly under challenging conditions.

CONCLUSIONS

Gait and balance impairments exist in people with HIV, resembling fall-associated parameters in the elderly. Impairments are more pronounced during challenging conditions, might be associated with disease severity, are not influenced by antiretroviral therapy, and might not be associated with peripheral neuropathy. Results should be interpreted cautiously due to overall poor methodological quality and heterogeneity. Locomotor impairments in adults with HIV are currently insufficiently quantified. Future research involving more methodological uniformity is warranted to better understand such impairments and to inform clinical decision-making, including fall-prevention strategies, in this population.

Osteopenia and the physical function in Japanese patients with schizophrenia

We evaluated the state of osteopenia and the physical function in 121 schizophrenic patients. These factors were worse in the inpatient group than in the outpatient group. The age, sex, body mass index (BMI), and physical function were correlated to the state of osteopenia. Physicians should consider the risk of osteopenia in elderly female psychiatric patients with low BMI.

PURPOSE

Information about the actual state of osteopenia in patients with schizophrenia is limited. In the present study, we evaluated the factors related to osteopenia and patient's physical function and compared these factors between inpatients and outpatients.

METHODS

A total of 121 schizophrenic patients were included in the present study. We divided the patients into two groups according to the therapeutic form. We collected data on their age, sex, body mass index (BMI), bone mineral density (BMD) in the lumbar spine and proximal femur, serum bone metabolic markers, risk of fracture, and physical function.

RESULTS

The number of fractured vertebrae, risk of fracture, serum concentration of tartrate-resistant acid phosphatase 5b (TRACP-5b), and score of locomo25 were significantly higher and the BMI and BMD in the lumbar spine and proximal femur significantly lower in the inpatient group than in the outpatient group. A multiple regression analysis showed that the age, sex, BMI, the number of fractured vertebrae, and score of locomo 25 were correlated with the BMD in the lumbar spine and proximal femur. Neither the therapeutic form nor any bone metabolic markers were correlated with the BMD. The inpatient group had a lower average BMI, BMD, and physical function than the outpatient group. However, a multiple regression analysis showed that the therapeutic form was not correlated with the BMD.

CONCLUSION

These findings suggest that physicians should consider elderly female schizophrenic patients with a low BMI to be at risk of developing osteopenia.

Current status of HIV/AIDS in the ART era

Human immunodeficiency virus (HIV) spread to humans from chimpanzees (HIV-1 groups M and N), gorillas (HIV-1 groups P and O), and sooty mangabeys (HIV-2). HIV is spread mainly through blood or body fluids. Subjects can become infected with HIV by sexual contact, needle sharing, blood transfusions, or maternal transmissions as a blood-borne virus or via breast-milk. The incubation period of HIV-1 from infection to the development of AIDS ranges from 8 to 11 years. In the past 3 decades, HIV has caused a great burden to global wealth and health. According to the WHO global health survey, 36.7 million people were infected with HIV, causing 1.1 million deaths in 2015. Since the discovery of HIV-1, many anti-retroviral drugs have been developed. Following the discovery and wide-spread use of anti-retroviral therapy (ART) the life expectancy of HIV infected individuals has substantially increased. By 2015, all major guidelines recommended treating all HIV-infected adults regardless of their CD4 count. Despite effective ART with virological suppression, HIV-associated neurocognitive disorders (HAND), cardiovascular diseases (CVD), metabolic syndrome (MS), bone abnormalities and non-HIV-associated malignancies remain a major complication associated with HIV infection. In this review article, I would like to describe recent ART status and problems in the ART-era.

Ageing and inflammation in patients with HIV infection

Nowadays, HIV⁺ patients have an expected lifespan that is only slightly shorter than healthy individuals. For this reason, along with the fact that infection can be acquired at a relatively advanced age, the effects of ageing on HIV⁺ people have begun to be evident. Successful anti-viral treatment is, on one hand, responsible for the development of side effects related to drug toxicity; on the other hand, it is not able to inhibit the onset of several complications caused by persistent immune activation and chronic inflammation. Therefore, patients with a relatively advanced age, i.e. aged more than 50 years, can experience pathologies that affect much older citizens. HIV⁺ individuals with non-AIDS-related complications can thus come to the attention of clinicians because of the presence of neurocognitive disorders, cardiovascular diseases, metabolic syndrome, bone abnormalities and non-HIV-associated cancers. Chronic inflammation and immune activation, observed typically in elderly people and defined as 'inflammaging', can be present in HIV⁺ patients who experience a type of premature ageing, which affects the quality of life significantly. This relatively new condition is extremely complex, and important factors have been identified as well as the traditional behavioural risk factors, e.g. the toxicity of anti-retroviral treatments and the above-mentioned chronic inflammation leading to a functional decline and a vulnerability to injury or pathologies. Here, we discuss the role of inflammation and immune activation on the most important non-AIDS-related complications of chronic HIV infection, and the contribution of aging per se to this scenario.