Clinical review. Risk factors for low bone mass-related fractures in men: a systematic review and meta-analysis

The incremental risk of fragility fractures in aging men

INTRODUCTION

While the United States Preventative Services Task Force recommends osteoporosis screening for women 65 years and older, there is no definitive recommendation for routine osteoporosis screening in men. The purpose of this study was to determine the age at which the odds of fragility fractures (FFx) increase in men to help guide future policy discussions evaluating an optimal screening strategy in this population.

METHODS

Men older than 49 years were identified in the PearlDiver Patient Records Database. Patients were excluded if they had a prior fragility fracture, if they were at high risk for osteoporosis due to comorbidities, or if they carried a diagnosis of and/or were on treatment for osteoporosis. The prevalence of FFx was trended for each age group. A stratum-specific likelihood ratio (SSLR) analysis was conducted to identify data-driven strata that maximize the incremental FFx risk by age for men. Logistic regression analyses controlling for potential confounders were conducted to test these identified strata.

RESULTS

The incidence of FFx started to increase after the age of 64 years for men. Further, the identified data-driven age strata associated with a significant and incremental difference in fragility fractures were the following: 50-64, 65-69, 70-72, 73-75, 76-78, 79-80, and 81+. When compared to the youngest age stratum (50-64 years), multivariable regression showed the risk of fragility fracture incrementally increased starting in those aged 70-72 (RR, 1.31; 95% CI. 1.21-1.46; p < 0.001) with the highest risk in those aged 81+ (RR, 5.35; 95% CI, 5.10-5.62; p < 0.001).

CONCLUSION

In men without a pre-existing history of osteoporosis, the risk of fragility fractures starts to increase after the age of 70. Further work building upon these data may help to identify a specific age at which routine bone health screening in males can help to minimize fractures and their associated morbidity and mortality.

Diagnosis and Management of Osteoporosis: A Comprehensive Review of Guidelines

Importance

Osteoporosis causes increased morbidity and mortality, and thus poses a significant economic burden to the health systems worldwide.

Objective

The aim of this study was to review and compare the most recently published major guidelines on diagnosis and management of this common medical entity.

Evidence Acquisition

A thorough comparative review of the most influential guidelines from the RACGP (Royal Australian College of General Practitioners), the ESCEO-IOF (European Society for Clinical and Economic Aspects of Osteoporosis-International Osteoporosis Foundation), the NOGG (National Osteoporosis Guideline Group), the NAMS (North American Menopause Society), the ES (Endocrine Society), and the ACOG (American College of Obstetricians and Gynecologists) was conducted.

Results

The reviewed guidelines generally agree on the definition, the criteria, and investigations used to diagnose osteoporosis. They also concur regarding the risk factors for osteoporosis and the suggested lifestyle modifications (calcium and vitamin D intake, normal body weight, reduction of alcohol consumption, and smoking cessation). However, there is lack of consensus on indications for fracture risk assessment in the general population and the exact indications for bone mineral density assessment. Referral to a bone specialist is reserved for complex cases of osteoporosis (NOGG, NAMS, and ACOG) or in case of inadequate access to care (RACGP). The use of hip protectors to reduce the risk of fractures is supported by RACGP, NOGG, and NAMS, solely for high-risk elderly patients in residential care settings. All guidelines reviewed recognize the efficacy of the pharmacologic agents (ie, bisphosphonates, denosumab, hormone therapy, and parathyroid hormone analogs). Nonetheless, recommendations regarding monitoring of pharmacotherapy differ, primarily in the case of bisphosphonates. The proposed intervals of repeat bone mineral density testing after initiation of drug therapy are set at 2 years (RACGP), 1-3 years (NAMS, ES, and ACOG), or 3-5 years (ESCEO-IOF and NOGG). All guidelines agree upon the restricted use of bone turnover markers only in bone specialist centers for treatment monitoring purposes. Finally, the definition of treatment failure varies among the reviewed guidelines.

Conclusions

Osteoporosis is a distressing condition for women, mainly those of postmenopausal age. Thus, it seems of paramount importance to develop consistent international practice protocols for more cost-effective diagnostic and management techniques, in order to improve women's quality of life.

Low Circulating Valine Associate With High Risk of Hip Fractures

CONTEXT

Hip fractures constitute a major health concern. An adequate supply of amino acids is crucial to ensure optimal acquisition and remodeling of bone. Circulating amino acid levels have been proposed as markers of bone mineral density, but data on their ability to predict incident fractures are scarce.

OBJECTIVES

To investigate the associations between circulating amino acids and incident fractures.

METHODS

We used UK Biobank (n = 111 257; 901 hip fracture cases) as a discovery cohort and the Umeå Fracture and Osteoporosis (UFO) hip fracture study (hip fracture cases n = 2225; controls n = 2225) for replication. Associations with bone microstructure parameters were tested in a subsample of Osteoporotic Fractures in Men Sweden (n = 449).

RESULTS

Circulating valine was robustly associated with hip fractures in the UK Biobank (HR per SD increase 0.79, 95% CI 0.73-0.84), and this finding was replicated in the UFO study (combined meta-analysis including 3126 incident hip fracture cases, odds ratio per SD increase 0.84, 95% CI 0.80-0.88). Detailed bone microstructure analyses showed that high circulating valine was associated with high cortical bone area and trabecular thickness.

CONCLUSION

Low circulating valine is a robust predictor of incident hip fractures. We propose that circulating valine may add information for hip fracture prediction. Future studies are warranted to determine whether low valine is causally associated with hip fractures.

Association with sagittal alignment and osteoporosis-related fractures in outpatient women with osteoporosis

The baseline sagittal vertical axis (SVA) and pelvic tilt (PT) are independent risk factors of osteoporosis-related fractures in women with osteoporosis. We clarified the SVA and PT to predict the incidence of osteoporosis-related fractures.

PURPOSE

Sagittal alignment with osteoporosis women deteriorates with advancing age and sagittal alignment may indicate osteoporosis-related fractures in the future. However, whether the sagittal alignment predicts future osteoporosis-related fracture in patients with osteoporosis has not been clarified. We aimed to investigate the association between sagittal alignment and future osteoporosis-related fractures.

METHODS

This was a retrospective cohort study. Of the 313 participants (mean follow-up period, 2.9 years), 236 were included in the analysis. At baseline, we measured bone mineral density (BMD) of the lumbar spine and the femoral neck, sagittal vertical axis (SVA), thoracic kyphosis, pelvic incidence minus lumbar lordosis, sacral slope, pelvic tilt (PT), geriatric locomotive function scale (GLFS), two-step value, and stand-up test. The information on medications and the duration of treatment were reviewed from the medical records. Additionally, participants reported their history of falls at baseline. Multiple logistic regression analysis was used to determine the association of future osteoporosis-related fracture, and adjusted Odds ratios (OR) and 95% confidence interval (CI) were calculated with all predictors as covariates. All continuous variables were calculated using standardized OR (sOR).

RESULTS

Osteoporosis-related fractures occurred in 33 of 313 participants (10.5%). Multiple logistic regression analysis showed that a history of falls (OR =4.092, 95% CI: 1.029-16.265, p =0.045), SVA (sOR =4.228, 95% CI: 2.118-8.439, p <0.001), and PT (sOR =2.497, 95% CI: 1.087-5.733, p =0.031) were independent risk factors for future osteoporosis-related fractures.

CONCLUSIONS

This study revealed the SVA and PT to predict osteoporosis-related fractures.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

UMIN000036516 (April 1, 2019).

Angiotensin Receptor Blocker is Associated with a Lower Fracture Risk: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are widely used in the treatment of hypertension. Hypertension is often accompanied by osteoporosis. However, the relationship between ACEI/ARB and fractures remains controversial. The purpose of this meta-analysis was to update the potential relationship between ACEI/ARB and fractures.

METHODS

This meta-analysis was identified through PubMed, EMBASE, Cochrane Library, and Web of Science. Related studies about ACEI/ARB with the risk of fracture were published from inception to June 2022.

RESULTS

Nine qualified prospective designed studies, involving 3,649,785 subjects, were included in this analysis. Overall, the RRs of ACEI compared with the nonusers were 0.98 (95% CI: 0.88, 1.10; P < 0.001) for composite fractures and 0.96 (95% CI: 0.87, 1.05; P=0.048) for hip fractures; the RRs of ARB compared to the nonusers were 0.82 (95% CI: 0.73, 0.91; P < 0.001) for composite fractures and 0.85 (95% CI: 0.74, 0.97; P=0.028) for hip fractures. Furthermore, in the subgroup analysis, male may benefit from ARB (RR = 0.65, 95% CI: 0.49, 0.89, P=0.028), and the European may also benefit from ARB (RR = 0.86, 95% CI: 0.80, 0.93, P=0.015).

CONCLUSIONS

ACEI usage will not decrease the risk of osteoporosis fracture. On the contrary, ARB usage can decrease the risk of total fracture and hip fracture, especially for males and Europeans. Compared with ACEI, for patients at higher risk of fracture in cardiovascular diseases such as hypertension, the protective effect of ARB should be considered.

The importance of association between sexsteroids deficiency, reduction of bone mineral density and falling risk in men with implications in medical rehabilitation

Introduction. Endocrino-metabolic rehabilitation represent one of the most complex sector in clinical medicine, regarding functional rehabilitation. Sex hormones deficiency plays an important role in the etiology of osteoporosis in men. At the same time, with age, the trophic role of androgens on muscle decreases and determines an increased frequency of falls. The objective of our study is to determine the association between sexsteroids deficiency, reduction of bone mineral density (BMD) and falling risk in men. Methods. Our retrospective cross-sectional study included 146 men aged between 65–85 years with low BMD (study group) and 121 men with normal BMD (control group). The measurement of Total testosterone (Tt), free testosterone (Tf) and estradiol (E2) serum levels was performed using the immunoassay or the immunoenzymatic methods. Femoral neck and lumbar spine BMD was determined using Dual-energy X-ray absorptiometry (DEXA). The risk of falls was assessed by Tandem Standing, Up & Go, Chair – Rising and walking speed tests. Results. We found a significantly association between Tf and E2 deficiency and low BMD (p=0.007). Also, in men with reduced BMD (study group) we observed significant lower levels of Tf (p<0.001) and E2 (p=0.003) compared to control group. E2 deficiency was associated significantly with low BMD and increased fall risk (p=0.001). At the same time the results highlighted significant lower levels of Tf in patients with BMD reduction and increased risk of falls (p=0.002). Tt deficiency was not associated with BMD reduction (p=0.088) or increased risk of falling (p=0.277). Conclusions. This research revealed a significant association between male sexsteroids deficiency, low BMD and increase of falling risk, with implications in rehabilitation program. The risk of ostoporosis and for falling in man can be estimated by determining serum Tf and E2 levels. Keywords: sexsteroids deficiency; bone mineral density; falling risk,

Recommendations on the diagnosis, treatment and monitoring of testosterone deficiency in men

The relative proportional increase of the elderly population within many countries will become one of the most significant social transformations of the twenty-first century and, for the first time in history, persons aged 65 or above outnumbered children under five years of age globally. One in four persons living in Europe and Northern America will be aged 65 or over. One of the goals of ISSAM is to raise awareness of the special health needs of older men. Since a significant number of aging men will eventually become testosterone deficient, the Hypogonadism panel of ISSAM updates its guidelines.

Relationship between bone mineral density and fragility fracture risk: a case-control study in Changsha, China

Background

Fragility fracture is associated with bone mineral density (BMD), and most databases used in related researches are instrument-matched. Little is known about the relationship between BMD and fragility fracture risk of native Chinese, especially using local databases as reference databases.

Objective

To investigate relationship between BMD and risk of fragility fracture in native China.

Methods

3,324 cases, including 2,423 women (67.7 ± 8.9 years) and 901 men (68.4 ± 11.6 years) having radiological fragility fractures and 3,324 age- and gender-matched controls participated in the study. We measured BMD at posteroanterior spine and hip using dual-energy X-ray absorptiometry (DXA), calculated BMD measurement parameters based on our own BMD reference database.

Results

BMDs and mean T-scores were lower in case group (with clinical fragility) than in control group (without clinical fragility). In patients with fragility fractures, prevalence of lumbar osteoporosis, low bone mass, and normal BMD were 78.9 %, 19.3 %, and 1.8 %, respectively, in women, and 49.5, 44.8 %, and 5.7 %, respectively, in men. In hip, these prevalence rates were 67.2 %, 28.4 %, and 4.4 % in females, and 43.2 %, 45.9 %, and 10.9 % in males, respectively, showing differences between females and males. Multivariate Cox regression analysis showed that after adjusting age, height, weight, and body mass index, fracture hazard ratio (HR) increased by 2.7–2.8 times (95 % CI 2.5–3.1) and 3.6–4.1 times (95 %CI 3.0–5.1) for women and men respectively with decreasing BMD parameters. In both sexes, risk of fragility fracture increased approximately 1.6–1.7 times (95 % CI 1.5–1.8) for every 1 T-score reduction in BMD.

Conclusions

Risk of clinical fragility fracture increases with decreasing BMD measurement parameters and anthropometric indicators in native China, and fracture HR varies from gender and site.

Prevalence and associated factors of radiographic vertebral fractures in men: Rural population cross-sectional observation study in Japan

BACKGROUND

Osteoporotic fractures constitute a major health concern in both women and men, particularly with the aging population. Many potential risk factors of vertebral fractures (VFx) have been identified in women, but not in men. Several reports have focused on the quality of life (QOL) of clinically diagnosed VFx, but not much has been reported on quantified QOL scores of incidental radiographic VFx in men. This cross-sectional study aimed to investigate the associated factors and the influence of incident radiographic VFx on QOL of men.

METHODS

A total of 401 volunteer men aged 40 years or older (40-92 years) participated in this study. The mean age was 60.5 ± 11.8 years. Prevalent VFx were identified on the lateral lumbar spinal radiographs using the semiquantitative method. Bone mineral density, body composition, smoking, alcohol intake, past medical history, Mini-Mental State Examination, grip strength, gait speed, and biochemical markers were examined. QOL was evaluated using the 36-Item Short-Form Health Survey and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire.

RESULTS

Of the 401 subjects, 35 men (8.7%) had the prevalence of VFx. After adjustment for age, the presence of VFx was significantly associated with IGF-1 (odds ratio 0.985; p = 0.02). QOL scores were not significantly associated with VFx after adjustment for age.

CONCLUSIONS

IGF-1 is the mediator of growth hormone, and IGF-1 stimulates the proliferation, differentiation, and mineralization of osteoblastic cells. The prevalence of VFx in men was 8.7%, and IGF-1 was significantly lower in the VFx group than in the non-VFx group.

Racial and gender differences in the relationship between sarcopenia and bone mineral density among older adults

Both sarcopenia and low bone mineral density (BMD) have become public health concerns. We found that presarcopenic and/or sarcopenic individuals were more likely to have lower BMD. And this relationship has race and sex-specific discrepancy.

PURPOSE

The purpose of the study was to investigate the racial and gender differences in the relationship between sarcopenia and BMD among older adults.

METHODS

Totally, 5476 subjects (mean age = 65.7 ± 6.4) of non-Hispanic White (n = 3297), non-Hispanic Black (n = 1265), and non-Hispanic Asian (n = 914) were analyzed. Sarcopenia was defined according to the revised European consensus on definition and diagnosis of sarcopenia (EWGSOP2). General linear model and multivariable linear regression model were used to examine the relationship between sarcopenia and regional/whole body BMD stratified by race and sex. Adjustments were conducted for physiological, behavioral, and disease factors.

RESULTS

Comparing with normal older participants, presarcopenic and sarcopenic elderly were more likely to have lower BMD. Although the difference was not statistically significant in a few sub-groups, among the three racial groups, the strongest association between sarcopenia and BMD was found in non-Hispanic Black people, followed by non-Hispanic White people and non-Hispanic Asian people. In addition, significant differences of BMD across sarcopenia stages were found in more sub-groups in women than in men after adjusting for covariates.

CONCLUSIONS

In this older cohort, sarcopenia is significantly related to low regional/whole-body BMD, and these associations vary by race and sex. Consideration in race and sex is warranted when developing strategies to maintain or minimize BMD loss.

Osteoporosis in Men: A Review of an Underestimated Bone Condition

Osteoporosis is called the 'silent disease' because, although it does not give significant symptoms when it is not complicated, can cause fragility fractures, with serious consequences and death. Furthermore, the consequences of osteoporosis have been calculated to weigh heavily on the costs of health systems in all the countries. Osteoporosis is considered a female disease. Actually, the hormonal changes that occur after menopause certainly determine a significant increase in osteoporosis and the risk of fractures in women. However, while there is no doubt that women are more exposed to osteoporosis and fragility fractures, the literature clearly indicates that physicians tend to underestimate the osteoporosis in men. The review of the literature done by the authors shows that osteoporosis and fragility fractures have a high incidence also in men; and, furthermore, the risk of fatal complications in hip fractured men is higher than that for women. The authors report the evidence of the literature on male osteoporosis, dwelling on epidemiology, causes of osteoporosis in men, diagnosis, and treatment. The analysis of the literature shows that male osteoporosis is underscreened, underdiagnosed, and undertreated, both in primary and secondary prevention of fragility fractures.

Testosterone and Bone Health in Men: A Narrative Review

Bone fracture due to osteoporosis is an important issue in decreasing the quality of life for elderly men in the current aging society. Thus, osteoporosis and bone fracture prevention is a clinical concern for many clinicians. Moreover, testosterone has an important role in maintaining bone mineral density (BMD) among men. Some testosterone molecular mechanisms on bone metabolism have been currently established by many experimental data. Concurrent with a decrease in testosterone with age, various clinical symptoms and signs associated with testosterone decline, including decreased BMD, are known to occur in elderly men. However, the relationship between testosterone levels and osteoporosis development has been conflicting in human epidemiological studies. Thus, testosterone replacement therapy (TRT) is a useful tool for managing clinical symptoms caused by hypogonadism. Many recent studies support the benefit of TRT on BMD, especially in hypogonadal men with osteopenia and osteoporosis, although a few studies failed to demonstrate its effects. However, no evidence supporting the hypothesis that TRT can prevent the incidence of bone fracture exists. Currently, TRT should be considered as one of the treatment options to improve hypogonadal symptoms and BMD simultaneously in symptomatic hypogonadal men with osteopenia.

Differential responses of bone to angiotensin II and angiotensin(1-7): beneficial effects of ANG(1-7) on bone with exposure to high glucose

Osteoporosis, diabetes, and hypertension are common concurrent chronic disorders. This study aimed to explore the respective effects of angiotensin II (ANG II) and angiotensin(1-7) [ANG(1-7)], active peptides in the renin-angiotensin system, on osteoblasts and osteoclasts under high-glucose level, as well as to investigate the osteo-preservative effects of ANG II type 1 receptor (AT1R) blocker and ANG(1-7) in diabetic spontaneously hypertensive rats (SHR). ANG II and ANG(1-7), respectively, decreased and increased the formation of calcified nodules and alkaline phosphatase activity in MC3T3-E1 cells under high-glucose level, and respectively stimulated and inhibited the number of matured osteoclasts and pit resorptive area in RANKL-induced bone marrow macrophages. Olmesartan and Mas receptor antagonist A779 could abolish those effects. ANG II and ANG(1-7), respectively, downregulated and upregulated the expressions of osteogenesis factors in MC3T3-E1 cells. ANG II promoted the expressions of cathepsin K and MMP9 in RAW 264.7 cells, whereas ANG(1-7) repressed these osteoclastogenesis factors. ANG II rapidly increased the phosphorylation of Akt and p38 in RAW 264.7 cells, whereas ANG(1-7) markedly reduced the phosphorylation of p38 and ERK under high-glucose condition. After treatments of diabetic SHR with valsartan and ANG(1-7), a significant increase in trabecular bone area, bone mineral density, and mechanical strength was only found in the ANG(1-7)-treated group. Treatment with ANG(1-7) significantly suppressed the increase in renin expression and ANG II content in the bone of SHR. Taken together, ANG II/AT1R and ANG(1-7)/Mas distinctly regulated the differentiation and functions of osteoblasts and osteoclasts upon exposure to high-glucose condition. ANG(1-7) could protect SHR from diabetes-induced osteoporosis.

Clinician's guide for the management and research of osteoporosis in North African men: a guidelines comparison, a cost-effectiveness analysis, and a local algorithm

A local management algorithm and practice recommendations for the management of osteoporosis in Egyptian males were developed after assessing the applicability of current international recommendations and the cost effectiveness of local drugs. A systematic review and sensitivity analyses augmented the quality of the research efforts.

PURPOSE

Osteoporosis affects both men and women; however, no local recommendations for the condition are available for the male population. Therefore, this study was undertaken to produce recommendations for men based on the applicability of current international recommendations and the cost effectiveness of local drugs.

METHODS

The International Osteoporosis Foundation website, EMBASE, and SUMSEARCH-2 databases were searched to identify all guidelines that included recommendations for males. Regional and international guidelines were then appraised using the Advancing Guideline Development, Reporting, and Evaluation in Healthcare-II tool. A cost-effectiveness analysis was conducted using the perspective of an uninsured patient, international outcomes, and local costs. Recommendations were then formulated using the Grading of Recommendations Assessment, Development and Evaluation guidelines, and symbolic representations.

RESULTS

Twenty-six guidelines were found. Only one of the guidelines focused entirely on males, with the remainder making inferences based on recommendations for females. Six regional guidelines were mainly of low quality. Alendronate was considered to be the most cost-effective drug, while teriparatide was found to be unaffordable.

CONCLUSION

Recommendations for men with osteoporosis are based on that of women, and the topic lacks exploration in the Middle East. International recommendations and other guidelines were evaluated and adopted to create guidance for the management of osteoporosis in men for application in Egypt.

Association between sedentary behavior and bone mass in adolescents

The effects of sedentary behavior on adolescents' bone health are controversial because, even in normal weight individuals, the excessive time spent in some specific types of these behaviors appears to have no negative effect on bone health.

PURPOSE

To analyze the relationship between sedentary behaviors and bone mass in adolescents.

METHODS

One hundred four adolescent boys and girls, aged 10 to 14 years, were divided into normal weight and overweight according to weight status. Specific sedentary behaviors (time spent on the Internet for school and non-school purposes, using the computer, watching television, and playing videogames) were assessed by questionnaire, and the total sedentary behavior time by accelerometry. Bone parameters were collected using X-ray absorptiometry, using total and lumbar bone mineral density (BMD) and total and lumbar bone mineral content (BMC) values.

RESULTS

In both groups, the time spent on the Internet for non-school purposes was positively correlated to the total and lumbar BMD. Also, while in the overweight group, the time spent using the computer was negatively correlated to lumbar BMD, and the time spent on the Internet for non-school purposes was positively correlated to the total and lumbar BMC, and in the normal weight group, the time spent on the Internet for non-school purposes was positively correlated to lumbar BMC.

CONCLUSIONS

Adolescents who spend more time in sedentary behavior, especially using the Internet for non-school purposes, have higher BMD and BMC, while normal weight adolescents who spend more time on the computer have lower BMD.

Smoking-Induced Risk of Osteoporosis Is Partly Mediated by Cadmium From Tobacco Smoke: The MrOS Sweden Study

Cigarette smoking is a risk factor for osteoporosis and bone fracture. Moreover, smoking causes exposure to cadmium, which is a known risk factor for osteoporosis. It is hypothesized that part of smoking-induced osteoporosis may be mediated via cadmium from tobacco smoke. We investigated this hypothesis using mediation analysis in a Swedish cohort of elderly men. This study was performed in 886 elderly men from the Swedish cohort of the Osteoporotic Fractures in Men (MrOS) study. Urinary samples, bone mineral density (BMD), smoking data, and other background information were obtained at baseline in 2002-2004. Urinary cadmium was analyzed in baseline samples and adjusted for creatinine. The cohort was followed until August 2018 for fracture incidence, based on the X-ray register. Mediation analysis was conducted to evaluate the indirect effect (via cadmium) of smoking on both BMD and fractures. Time to first fracture was analyzed using the accelerated failure time (AFT) model and Aalen's additive hazard model. The mean level of urinary cadmium was 0.25 μg/g creatinine. There were significant inverse associations between smoking and total body, total hip, and trochanter BMD. The indirect effects via cadmium were estimated to be 43% of the total effects of smoking for whole-body BMD, and even more for total hip and trochanter BMD. Smoking was also associated with higher risk of all fractures and major osteoporosis fractures. The indirect effects via cadmium were largest in nonvertebral osteoporosis fractures and hip fractures, constituting at least one-half of the total effects, in both the AFT and Aalen's model. The findings in this study provide evidence that cadmium exposure from tobacco smoke plays an important role in smoking-induced osteoporosis © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Oxidative stress and anabolic hormones in back pain: Current concept and preliminary analysis in male cohort

Back Pain (BP) is a common medical problem; anabolic hormones, through the modulation of oxidative stress (OS), could influence fracture risk. We evaluated the prevalence of anabolic hormonal deficiencies and their relationship with OS in males with BP, associated or not to nontraumatic fractures. 49 males with BP, from 36 to 80 years, were divided in two groups according to radiological evidence of nontraumatic fractures; group A (n=25): non-fractured; group B (n=24): fractured. A different prevalence of hormonal deficits was observed: 24% of hypotestosteronemia in A, 0% in B; 16% of GHD in A, 29% in B; Total Antioxidant Capacity (TAC) showed a trend toward higher levels in B. In A, despite lower TAC, a significant inverse correlation was present between TAC and IGF-1. A greater prevalence of GHD in patients with vertebral fractures was seen and, in a subgroup, OS could mediate the deleterious effects of hyposecretory GH state.

Epidemiology of low-energy wrist, hip, and spine fractures in Chinese populations 50 years or older: A national population-based survey

The aim of the study was to investigate the incidence of low-energy fracture of wrist, hip, and spine and the related risk factors in Chinese populations 50 years or older.This study was a part of the Chinese National Fracture Survey (CNFS) carried out in 8 Chinese provinces in 2015. Data on 154,099 Chinese men and women 50 years or older were extracted from the CNFS database for calculations and analyses. Low-energy fracture was defined as fracture caused by slip, trip, or falls from standing height.A total of 247 patients sustained low-energy fractures in 2014, indicating the incidence rate was 160.3/100,000 person-years, with 120.0 [95% confidence interval (CI), 95.5-144.5] and 213.1(95% CI, 180.7-245.6)/100,000 person-years in men and women, respectively. In men, advanced age, alcohol consumption, residence at second floor or above without elevator, sleep duration <7 h/day, and history of past fracture were identified to be significant risk factors for low-energy fractures. In women, advanced age, living in east region, higher latitude zone (40°N -49.9°N), alcohol consumption, more births, sleep duration <7 h/day, and history of past fracture were identified as significant risk factors. Supplementation of calcium or vitamin D or both was identified to be associated with reduced risk of fracture in women (odds ratio, 0.38; 95% CI, 0.20-0.75), but not in men.These epidemiologic data on low-energy fractures provided updated clinical evidence base for national healthcare planning and preventive efforts in China. Corresponding interventions such as decreasing alcohol consumption and sleep improvement should clearly be implemented. For women, especially those with more births and past history of fracture, routine screening of osteoporosis, and intensive nourishment since menopause should be advocated.

Thiazide Diuretics and the Incidence of Osteoporotic Fracture: A Systematic Review and Meta-Analysis of Cohort Studies

Background: Thiazide diuretics may improve bone mineral density. However, results are inconsistent for studies evaluating the association between thiazides and risk of osteoporotic fracture. We performed an updated meta-analysis of cohort studies to determine the association between thiazides use and fracture risk.

Methods: Relevant studies were identified via systematic search of PubMed and Embase. A random-effect model was used for meta-analysis. Subgroup analyses were performed to explore the potential influences of study characteristics on the outcome.

Results: Seventeen cohort studies with 3,537,504 participants were included. The pooled results showed that use of thiazide diuretics at baseline did not significantly affect the risk of overall osteoporotic fracture incidence as compared with controls (risk ratio [RR]: 0.96, 95% confidence interval [CI]: 0.83 to 1.09, p = 0.51) with significant heterogeneity (p for Cochrane’s Q test < 0.001, I² = 90%). Results of subgroup analyses indicated that general status of the participants may be an important determinant for the association between thiazide diuretics and subsequent risk of osteoporotic fracture. Use of thiazide diuretics was associated with significantly reduced risk of fracture in patients with acute status including new-onset stroke or spinal cord injury (RR: 0.70, 95% CI: 0.57 to 0.86, p < 0.001), but not in those with good conditions such as community-dwelling population or hypertensive patients (p for subgroup difference = 0.02).

Conclusions: Use of thiazide diuretics is not associated with significantly affected risk of overall osteoporotic fracture. However, the association may be different according to the general status of the participants.

Management of Osteoporosis in Survivors of Adult Cancers With Nonmetastatic Disease: ASCO Clinical Practice Guideline

PURPOSE

The aim of this work is to provide evidence-based guidance on the management of osteoporosis in survivors of adult cancer.

METHODS

ASCO convened a multidisciplinary Expert Panel to develop guideline recommendations based on a systematic review of the literature.

RESULTS

The literature search of the 2018 systematic review by the US Preventive Services Task Force in the noncancer population was used as the evidentiary base upon which the Expert Panel based many of its recommendations. A total of 61 additional studies on topics and populations not covered in the US Preventive Services Task Force review were also included. Patients with cancer with metastatic disease and cancer survival outcomes related to bone-modifying agents are not included in this guideline.

RECOMMENDATIONS

Patients with nonmetastatic cancer may be at risk for osteoporotic fractures due to baseline risks or due to the added risks that are associated with their cancer therapy. Clinicians are advised to assess fracture risk using established tools. For those patients with substantial risk of osteoporotic fracture, the clinician should obtain a bone mineral density test. The bone health of all patients may benefit from optimizing nutrition, exercise, and lifestyle. When a pharmacologic agent is indicated, bisphosphonates or denosumab at osteoporosis-indicated dosages are the preferred interventions.

Risk of Osteoporosis and Fractures in Patients with Thyroid Cancer: A Case-Control Study in U.S. Veterans

BACKGROUND

Data on osteoporosis and fractures in patients with thyroid cancer, especially men, are conflicting. Our objective was to determine osteoporosis and fracture risk in U.S. veterans with thyroid cancer.

MATERIALS AND METHODS

This is a case-control study using the Veterans Health Administration Corporate Data Warehouse (2004-2013). Patients with thyroid cancer (n = 10,370) and controls (n = 10,370) were matched by age, sex, weight, and steroid use. Generalized linear mixed-effects regression model was used to compare the two groups in terms of osteoporosis and fracture risk. Next, subgroup analysis of the patients with thyroid cancer using longitudinal thyroid-stimulating hormone (TSH) was performed to determine its effect on risk of osteoporosis and fractures. Other covariates included patient age, sex, median household income, comorbidities, and steroid and androgen use.

RESULTS

Compared with controls, osteoporosis, but not fractures, was more frequent in patients with thyroid cancer (7.3% vs. 5.3%; odds ratio [OR], 1.33; 95% confidence interval [CI], 1.18-1.49) when controlling for median household income, Charlson/Deyo comorbidity score, and androgen use. Subgroup analysis of patients with thyroid cancer demonstrated that lower TSH (OR, 0.93; 95% CI, 0.90-0.97), female sex (OR, 4.24; 95% CI, 3.53-5.10), older age (e.g., ≥85 years: OR, 17.18; 95% CI, 11.12-26.54 compared with <50 years), and androgen use (OR, 1.63; 95% CI, 1.18-2.23) were associated with osteoporosis. Serum TSH was not associated with fractures (OR, 1.01; 95% CI, 0.96-1.07).

CONCLUSION

Osteoporosis, but not fractures, was more common in U.S. veterans with thyroid cancer than controls. Multiple factors may be contributory, with low TSH playing a small role.

IMPLICATIONS FOR PRACTICE

Data on osteoporosis and fragility fractures in patients with thyroid cancer, especially in men, are limited and conflicting. Because of excellent survival rates, the number of thyroid cancer survivors is growing and more individuals may experience long-term effects from the cancer itself and its treatments, such as osteoporosis and fractures. The present study offers unique insight on the risk for osteoporosis and fractures in a largely male thyroid cancer cohort. Physicians who participate in the long-term care of patients with thyroid cancer should take into consideration a variety of factors in addition to TSH level when considering risk for osteoporosis.

Long-term use of inhaled glucocorticoids in patients with stable chronic obstructive pulmonary disease and risk of bone fractures: a narrative review of the literature

Patients with chronic obstructive pulmonary disease (COPD) demonstrate a greater osteoporosis prevalence than the general population. This osteoporosis risk may be enhanced by treatment with inhaled corticosteroids (ICSs), which are recommended for COPD management when combined with long-acting bronchodilators, but may also be associated with reduced bone mineral density (BMD). We conducted a narrative literature review reporting results of randomized controlled trials (RCTs) of an ICS versus placebo over a treatment period of at least 12 months, with the aim of providing further insight into the link between bone fractures and ICS therapy. As of 16 October 2017, we identified 17 RCTs for inclusion. The ICSs studied were budesonide (six studies), fluticasone propionate (five studies), mometasone furoate (three studies), beclomethasone dipropionate, triamcinolone acetonide, and fluticasone furoate (one each). We found no difference in the number of bone fractures among patients receiving ICSs versus placebo across the six identified RCTs reporting fracture data. BMD data were available for subsets of patients in few studies, and baseline BMD data were rare; where these data were given, they were reported for treatment groups without stratification for factors known to affect BMD. Risk factors for reduced BMD and fractures, such as smoking and physical activity, were also often not reported. Furthermore, a standardized definition of the term "fracture" was not employed across these studies. The exact relationship between long-term ICS use and bone fracture incidence in patients with stable COPD remains unclear in light of our review. We have, however, identified several limiting factors in existing studies that may form the basis of future RCTs designed specifically to explore this relationship.

Protective Effects of Ligustroflavone, an Active Compound from Ligustrum lucidum, on Diabetes-Induced Osteoporosis in Mice: A Potential Candidate as Calcium-Sensing Receptor Antagonist

Ligustroflavone is one major compound contained in active fraction from Fructus Ligustri Lucidi (the fruit of Ligustrum lucidum), which could regulate parathyroid hormone (PTH) levels and improve calcium balance by acting on calcium-sensing receptors (CaSR). This study aimed to explore the potency of ligustroflavone as a CaSR antagonist and its protective effects against diabetic osteoporosis in mice. LF interacted well with the allosteric site of CaSR shown by molecular docking analysis, increased PTH release of primary parathyroid gland cells and suppressed extracellular calcium influx in HEK-293 cells. The serum level of PTH attained peak value at 2 h and maintained high during the period of 1 h and 3 h than that before treatment in mice after a single dose of LF. Treatment of diabetic mice with LF inhibited the decrease in calcium level of serum and bone and the enhancement in urinary calcium excretion as well as elevated circulating PTH levels. Trabecular bone mineral density and micro-architecture were markedly improved in diabetic mice upon to LF treatment for 8 weeks. LF reduced CaSR mRNA and protein expression in the kidneys of diabetic mice. Taken together, ligustroflavone could transiently increase PTH level and regulate calcium metabolism as well as prevent osteoporosis in diabetic mice, suggesting that ligustroflavone might be an effective antagonist on CaSR.

Special form of osteoporosis in a 53-year-old man

Male osteoporosis often remains unrecognised. Osteoporotic fractures occur approximately 10 years later in men than in women due to higher peak bone mass. However, 30% of all hip fractures occur in men. Risk factors of osteoporotic fractures can be grouped into primary and secondary causes. We present the case of a 53-year-old man, who suffered a compression fracture of a lumbar vertebra after a generalised seizure and an atraumatic rib fracture 5 months later. We could exclude secondary causes of bone mineral loss such as primary hyperparathyroidism, glucocorticoid use and hypogonadism. However, a heterozygous missense mutation of the COL1A1 gene in exon 48 in further search of a secondary cause was found. Therapy was changed from bisphosphonate treatment to teriparatide. Considering the lack of other osteogenesis imperfecta (OI) symptoms and signs, the patient's illness can be classified as mild. OI should be considered as differential diagnosis in unexplained cases with osteoporosis.

What nutritional factors influence bone mineral density in Crohn's disease patients?

Background/Aims

Bone mineral density (BMD) is often low in patients with Crohn's disease (CD). This study aimed to evaluate the association between nutritional factors and BMD in a group of CD patients.

Methods

CD patients 18 years of age or older were included. The body mass index (BMI), waist circumference (WC) and dietary intake were evaluated during two 24-hour recalls. Bone densitometry was performed by dual-energy X-ray absorptiometry of the full body to assess body composition and of the lumbar vertebrae and femoral neck to assess BMD.

Results

In the 60 patients evaluated, there was no association between BMD and disease activity or between BMD and disease duration. We observed moderate correlations between BMD in at least one of the evaluated sites and BMI, lean mass, WC, and protein, calcium, phosphorus and magnesium dietary intakes (P<0.05). In the linear regression analysis for spinal BMD, only BMI and calcium dietary intake remained associated (P<0.05). In the linear regression analysis for femoral BMD, WC and phosphorus intake continued to be significant in the final model, although they had low explanatory power for BMD (P<0.05).

Conclusions

The prevalence of low BMD was high in CD patients. BMI, WC, calcium and phosphorus dietary intake were positively correlated with BMD.

Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

By 2020, approximately 12.3 million individuals in the United States older than 50 years are expected to have osteoporosis. Osteoporotic fractures, particularly hip fractures, are associated with limitations in ambulation, chronic pain and disability, loss of independence, and decreased quality of life, and 21% to 30% of patients who experience a hip fracture die within 1 year. The prevalence of primary osteoporosis (ie, osteoporosis without underlying disease) increases with age and differs by race/ethnicity. With the aging of the US population, the potential preventable burden is likely to increase in future years.

OBJECTIVE

To update the 2011 US Preventive Services Task Force (USPSTF) recommendation on screening for osteoporosis.

EVIDENCE REVIEW

The USPSTF reviewed the evidence on screening for and treatment of osteoporotic fractures in men and women, as well as risk assessment tools, screening intervals, and efficacy of screening and treatment in subgroups. The screening population was postmenopausal women and older men with no known previous osteoporotic fractures and no known comorbid conditions or medication use associated with secondary osteoporosis.

FINDINGS

The USPSTF found convincing evidence that bone measurement tests are accurate for detecting osteoporosis and predicting osteoporotic fractures in women and men. The USPSTF found adequate evidence that clinical risk assessment tools are moderately accurate in identifying risk of osteoporosis and osteoporotic fractures. The USPSTF found convincing evidence that drug therapies reduce subsequent fracture rates in postmenopausal women. The USPSTF found that the evidence is inadequate to assess the effectiveness of drug therapies in reducing subsequent fracture rates in men without previous fractures.

CONCLUSIONS AND RECOMMENDATION

The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. (B recommendation) The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men. (I statement).

The epidemiology of wrist fractures in older men: the Osteoporotic Fractures in Men (MrOS) study

There is limited wrist fracture information on men. Our goal was to calculate frequency and identify risk factors for wrist fracture in the Osteoporotic Fractures in Men (MrOS) study. We confirmed that fracture history and certain medications are predictors, and identified novel predictors including markers of kidney function and physical performance.

INTRODUCTION

To calculate the incidence of wrist fractures and their risk factors in older community-dwelling men from the US Osteoporotic Fractures in Men (MrOS) study.

METHODS

Using triannual postcards, we identified incident wrist fractures (centrally confirmed by radiology) in men aged ≥ 65. Potential risk factors included the following: demographics, lifestyle, bone mineral density (BMD), selected medications, biomarkers, and physical function and performance measures. Both baseline and time-varying models were adjusted for age, race/ethnicity, MrOS geographic location, and competing mortality risks.

RESULTS

We observed 97 incident wrist fractures among 5875 men followed for an average of 10.8 years. The incidence of wrist fracture was 1.6 per 1000 person-years overall and ranged from 1.0 among men aged 65-69 to 2.4 among men age ≥ 80. Significant predictors included the following: fracture history after age 50 [hazard ratio (95% CI): 2.48 (1.65, 3.73)], high serum phosphate [1.25 (1.02, 1.53)], use of selective serotonin receptor inhibitor (SSRI) [3.60 (1.96, 6.63), decreased right arm BMD [0.49 (0.37, 0.65) per SD increase], and inability to perform the grip strength test [3.38 (1.24, 9.25)]. We did not find associations with factors commonly associated with wrist and other osteoporosis fractures like falls, diabetes, calcium and vitamin D intake, and alcohol intake.

CONCLUSIONS

Among these older, community-dwelling men, we confirmed that fracture history is a strong predictor of wrist fractures in men. Medications such as SSRIs and corticosteroids also play a role in wrist fracture risk. We identified novel risk factors including kidney function and the inability to perform the grip strength test.

Comparison of three tools for predicting primary osteoporosis in an elderly male population in Beijing: a cross-sectional study

Purpose

In this cross-sectional study, three clinical tools, the Osteoporosis Self-Assessment Tool for Asians (OSTA), Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD), and body mass index (BMI), for predicting primary osteoporosis (OP) were compared and ideal thresholds for omission of screening BMD were proposed in a community-dwelling elderly Han Beijing male population.

Patients and methods

A total of 1,349 community-dwelling elderly Han Beijing males aged ≥50 years were enrolled in this study. All subjects completed a questionnaire and measured BMD by dual-energy X-ray absorptiometry (DXA). Osteoporosis was defined as a T-score of -2.5 SD or lower than that of the average young adult in different diagnostic criteria (lumbar spine [L1-L4], femoral neck, total hip, worst hip, and World Health Organization [WHO]). FRAX without BMD, OSTA, and BMI were assessed for predicting OP by receiver operating characteristic (ROC) curves. Sensitivity, specificity, and areas under the ROC curves (AUCs) were determined. Ideal thresholds for omission of screening BMD were proposed.

Results

The prevalence of OP ranged from 1.8% to 12.8% according to different diagnostic criteria. This study showed that the BMI has highest discriminating ability. The AUC of FRAX without BMD ranged from 0.536 to 0.630, which suggested limiting predictive value for identifying OP in elderly Beijing male. The AUCs of BMI (0.801-0.880) were slightly better than OSTA (0.722-0.874) in predicting OP at all sites. The AUC of BMI to identify OP in worst hip was 0.824, yielding a sensitivity of 84.8% and a specificity of 64.4%. 40% of participants on BMD measurements saved only 0.1%-2.7% missed OP. Compared to OSTA and FRAX without BMD, the BMI got the best predictive value for OP.

Conclusion

BMI may be a simple and effective tool for identifying OP in the elderly male population in Beijing to omit BMD screening reasonably.

Association between subclinical thyroid dysfunction and change in bone mineral density in prospective cohorts

BACKGROUND

Subclinical hyperthyroidism (SHyper) has been associated with increased risk of hip and other fractures, but the linking mechanisms remain unclear.

OBJECTIVE

To investigate the association between subclinical thyroid dysfunction and bone loss.

METHODS

Individual participant data analysis was performed after a systematic literature search in MEDLINE/EMBASE (1946-2016). Two reviewers independently screened and selected prospective cohorts providing baseline thyroid status and serial bone mineral density (BMD) measurements. We classified thyroid status as euthyroidism (thyroid-stimulating hormone [TSH] 0.45-4.49 mIU/L), SHyper (TSH < 0.45 mIU/L) and subclinical hypothyroidism (SHypo, TSH ≥ 4.50-19.99 mIU/L) both with normal free thyroxine levels. Our primary outcome was annualized percentage BMD change (%ΔBMD) from serial dual X-ray absorptiometry scans of the femoral neck, total hip and lumbar spine, obtained from multivariable regression in a random-effects two-step approach.

RESULTS

Amongst 5458 individuals (median age 72 years, 49.1% women) from six prospective cohorts, 451 (8.3%) had SHypo and 284 (5.2%) had SHyper. During 36 569 person-years of follow-up, those with SHyper had a greater annual bone loss at the femoral neck versus euthyroidism: %ΔBMD = -0.18 (95% CI: -0.34, -0.02; I2 = 0%), with a nonstatistically significant pattern at the total hip: %ΔBMD = -0.14 (95% CI: -0.38, 0.10; I2 = 53%), but not at the lumbar spine: %ΔBMD = 0.03 (95% CI: -0.30, 0.36; I2 = 25%); especially participants with TSH < 0.10 mIU/L showed an increased bone loss in the femoral neck (%Δ BMD = -0.59; [95% CI: -0.99, -0.19]) and total hip region (%ΔBMD = -0.46 [95% CI: -1.05, -0.13]). In contrast, SHypo was not associated with bone loss at any site.

CONCLUSION

Amongst adults, SHyper was associated with increased femoral neck bone loss, potentially contributing to the increased fracture risk.

Modifiable lifestyle factors associated with osteoporosis in Korean men: a case-control study

The prevention, education, and treatment of osteoporosis are all recognized as important components in men as well as women. This study revealed that the lifestyle factors associated with male osteoporosis included being underweight and being a current smoker. Being overweight or obese and having a regular exercise habit were negatively associated with male osteoporosis.

PURPOSE

Osteoporosis is a significant health problem in Korea and worldwide. Although osteoporosis is less prevalent in males than in females, the fracture-related mortality rate is higher in males than in females. The aim of this study was to investigate the relationship of modifiable lifestyle factors in males with osteoporosis.

METHODS

A case-control study was performed in men who visited a single university hospital for a medical check-up between August 2003 and July 2016. Patients were classified in the case group according to the World Health Organization (WHO) Osteoporosis Criteria. The control group was created by matching patients according to age and check-up date. Lifestyle factors were evaluated by a self-assessment questionnaire. Multivariate conditional logistic regression was used to examine the association between lifestyle factors and male osteoporosis with age stratification at 50 years.

RESULTS

A total of 1304 subjects were included in this analysis, 326 of whom were in the case group and 978 of whom were in the control group. Within their age group, subjects with osteoporosis were more often underweight (odds ratio [OR] = 2.35, 95% confidence interval [CI], 1.11-4.98) or more often current smokers (2.22, 1.50-3.28) than control subjects. The subjects who were overweight (0.45, 0.32-0.64), obese (0.19, 0.13-0.27), had an irregular exercise habit (0.64, 0.43-0.94), or had a regular exercise habit (0.40, 0.28-0.57) were more likely to have normal bone status. Alcohol drinking habit had no significant association with male osteoporosis.

CONCLUSIONS

Several modifiable lifestyle factors were associated with male osteoporosis. Current smokers at any age and underweight men below age 50 were more likely to have osteoporosis, whereas men who were overweight, obese, or had a regular exercise habit were more likely to have normal bone status, regardless of age.

Effect of mineral status and glucocorticoid use on bone mineral density in patients with Crohn's disease

OBJECTIVES

Crohn's disease (CD) is a condition that is characterized by chronic inflammation. The presence of multifactorial pathogenesis that results from inflammation is associated with low micronutrient consumption and glucocorticoid use, which may be related to bone health. This study aimed to evaluate the relationship between dietary mineral intake and glucocorticoid use in bone mineral density (BMD) in patients with CD.

METHODS

A cross-sectional study of 62 patients with CD ages 20 y to 40 y measured their macro- and micronutrient intake with a 3-d food record. The lumbar spine and femoral neck BMDs were determined using a bone densitometry technique. The C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) values were also noted.

RESULTS

Dietary intake of calcium, zinc, and magnesium was below the reference values but the phosphorus intake level was within the normal value range. Patients with osteopenia and osteoporosis accounted for 17.7% and 14.5%, respectively, of the total number of participants. Significant bone loss was found in 22.6% of patients taking glucocorticoid medications. BMD was significantly reduced and also observed in patients in the active phase of their disease. Zinc and calcium intakes were found to be correlated with reduced femoral neck BMD. The mean CRP and ESR values were above the normal ranges. Significant differences in age and ESR were observed between patients with normal and reduced BMD (P <0.05).

CONCLUSIONS

Low calcium and zinc intake, glucocorticoid use, and active disease phase are favorable conditions for bone loss in patients with Crohn's disease.

Risk of Sarcopenia and Osteoporosis in Male Tuberculosis Survivors: Korea National Health and Nutrition Examination Survey

Short-term prospective studies have suggested that pulmonary tuberculosis (TB) preludes permanent loss of lean tissue and fat mass even when TB treatment is effective. The aim of this study was to estimate the risk of sarcopenia and osteoporosis among Korean male TB survivors. Data of the population-based, Korea National Health and Nutrition Examination Survey (KNHANES) (2008–2011) were analyzed, including 3,228 males aged 50 years or older who underwent chest X-ray (CXR) and dual-energy x-ray absorptiometry (DEXA). TB survivors having both medical history and TB scars on CXR had increased risk of sarcopenia (odds ratio [OR] 3.44, 95% confidence interval [CI] 1.79–6.68) and osteoporosis (OR 1.75, 95% CI 1.04–2.95) after adjusting for age, height, smoking, alcohol, physical activity, serum 25-hydroxyvitamin D, parathyroid hormone level, education, and fat mass index. Having TB scars on CXR without medical history of TB was an independent risk factor of sarcopenia (OR 2.05, 95% CI 1.05–4.00), but not a risk factor of osteoporosis. Sarcopenia and low bone mineral density are prevalent in pulmonary TB survivors with TB scars on CXR. Medical history of TB with TB scars on CXR is an independent risk factor for sarcopenia and osteoporosis.

Glycinol enhances osteogenic differentiation and attenuates the effects of age on mesenchymal stem cells

AIM

Phytoestrogens, such as glycinol, have recently gained significant attention as an alternative therapy for osteoporosis due to their structural similarity to estradiol and their bone-generating potential.

METHODS

The osteogenic effects of glycinol were investigated in human bone marrow mesenchymal stem cells (BMSCs) derived from older (>50 years old) and younger subjects (<25 years old).

RESULTS

BMSCs isolated from older donors demonstrated reduced osteogenesis. 17β-estradiol and glycinol exposure rescued the age-related reduction in osteogenic differentiation of BMSCs. These results correlated with the induction of osteogenic genes and estrogen receptor-α (ER-α) following glycinol treatment. ER antagonist studies further support that glycinol promotes osteogenesis through ER signaling.

CONCLUSION

The results from these studies support investigating glycinol as a potential preventive or treatment for osteoporosis.

Chronic use of low-dose aspirin is not associated with lower bone mineral density in the general population

BACKGROUND

Low-dose aspirin is the cornerstone of secondary prevention of cardiovascular disease. Previous studies suggested that the use of aspirin is associated with an increased fracture risk. However, there is uncertainty whether this is due to an effect of aspirin on bone mineral density (BMD).

METHODS

Between 2008 and 2012, information on medication use and dual X-ray absorptiometry measured vertebral and femoral BMD of 916 participants was collected in the Netherland Epidemiology of Obesity study. The cross-sectional association between chronic low-dose aspirin use and BMD was estimated using linear regression, controlling for demography, body composition, comorbidity and other medication use which could affect BMD. A subgroup analysis in postmenopausal women (n=329) was conducted.

RESULTS

After full adjustment, there was no difference between aspirin users and non-users for vertebral BMD (adjusted mean difference: 0.036 (95% CI -0.027 to 0.100) g/cm²) and femoral BMD (adjusted mean difference: 0.001 (-0.067 to 0.069) g/cm²). Also in the subgroup of postmenopausal women, aspirin use was not associated with lower vertebral (adjusted mean difference: 0.069 (-0.046 to 0.184) g/cm²) or femoral BMD (adjusted mean difference: -0.055 (-0.139;0.029) g/cm²).

CONCLUSION

Chronic use of low-dose aspirin is not associated with lower BMD in the general population. The increased risk of fractures observed in aspirin users in previous studies is therefore more likely to be the result of common causes of aspirin use and fractures, but not of direct effects of aspirin on BMD.

Dementia and osteoporosis in a geriatric population: Is there a common link?

AIM

To determine the existence of a common pathological link between dementia and osteoporosis through reviewing the current evidence base.

METHODS

This paper reviews the current literature on osteoporosis and dementia in order to ascertain evidence of a common predisposing aetiology. A literature search of Ovid MED-LINE (1950 to June 2016) was conducted. The keywords “osteoporosis”, “osteoporotic fracture”, “dementia” and “Alzheimer’s disease” (AD) were used to determine the theoretical links with the most significant evidence base behind them. The key links were found to be vitamins D and K, calcium, thyroid disease, statins, alcohol and sex steroids. These subjects were then searched in combination with the previous terms and the resulting papers manually examined. Theoretical, in vitro and in vivo research were all used to inform this review which focuses on the most well developed theoretical common causes for dementia (predominantly Alzheimer’s type) and osteoporosis.

RESULTS

Dementia and osteoporosis are multifaceted disease processes with similar epidemiology and a marked increase in prevalence in elderly populations. The existence of a common link between the two has been suggested despite a lack of clear pathological overlap in our current understanding. Research to date has tended to be fragmented and relatively weak in nature with multiple confounding factors reflecting the difficulties of in vivo experimentation in the population of interest. Despite exploration of various possible mechanisms in search for a link between the two pathologies, this paper found that it is possible that these associations are coincidental due to the nature of the evidence available. One finding in this review is that prior investigation into common aetiologies has found raised amyloid beta peptide levels in osteoporotic bone tissue, with a hypothesis that amyloid beta disorders are systemic disorders resulting in differing tissue manifestations. However, our findings were that the most compelling evidence of a common yet independent aetiology lies in the APOE4 allele, which is a well-established risk for AD but also carries an independent association with fracture risk. The mechanism behind this is thought to be the reduced plasma vitamin K levels in individuals exhibiting the APOE4 allele which may be amplified by the nutritional deficiencies associated with dementia, which are known to include vitamins K and D. The vitamin theory postulates that malnutrition and reduced exposure to sunlight in patients with AD leads to vitamin deficiencies.

CONCLUSION

Robust evidence remains to be produced regarding potential links and regarding the exact aetiology of these diseases and remains relevant given the burden of dementia and osteoporosis in our ageing population. Future research into amyloid beta, APOE4 and vitamins K and D as the most promising aetiological links should be welcomed.

Incidence and risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture: A systematic review and meta-analysis

BACKGROUND

This study aimed to quantitatively summarize the risk factors associated with surgical site infection after open reduction and internal fixation of tibial plateau fracture.

METHODS

Medline, Embase, CNKI, Wanfang database and Cochrane central database were searched for relevant original studies from database inception to October 2016. Eligible studies had to meet quality assessment criteria according to the Newcastle-Ottawa Scale, and had to evaluate the risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture. Stata 11.0 software was used for this meta-analysis.

RESULTS

Eight studies involving 2214 cases of tibial plateau fracture treated by open reduction and internal fixation and 219 cases of surgical site infection were included in this meta-analysis. The following parameters were identified as significant risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture (p < 0.05): open fracture (OR 3.78; 95% CI 2.71-5.27), compartment syndrome (OR 3.53; 95% CI 2.13-5.86), operative time (OR 2.15; 95% CI 1.53-3.02), tobacco use (OR 2.13; 95% CI 1.13-3.99), and external fixation (OR 2.07; 95% CI 1.05-4.09). Other factors, including male sex, were not identified as risk factors for surgical site infection.

CONCLUSION

Patients with the abovementioned medical conditions are at risk of surgical site infection after open reduction and internal fixation of tibial plateau fracture. Surgeons should be cognizant of these risks and give relevant preoperative advice.

Male Hypogonadism and Osteoporosis: The Effects, Clinical Consequences, and Treatment of Testosterone Deficiency in Bone Health

It is well recognized that bone loss accelerates in hypogonadal states, with female menopause being the classic example of sex hormones affecting the regulation of bone metabolism. Underrepresented is our knowledge of the clinical and metabolic consequences of overt male hypogonadism, as well as the more subtle age-related decline in testosterone on bone quality. While menopause and estrogen deficiency are well-known risk factors for osteoporosis in women, the effects of age-related testosterone decline in men on bone health are less well known. Much of our knowledge comes from observational studies and retrospective analysis on small groups of men with variable causes of primary or secondary hypogonadism and mild to overt testosterone deficiencies. This review aims to present the current knowledge of the consequences of adult male hypogonadism on bone metabolism. The direct and indirect effects of testosterone on bone cells will be explored as well as the important differences in male osteoporosis and assessment as compared to that in females. The clinical consequence of both primary and secondary hypogonadism, as well as testosterone decline in older males, on bone density and fracture risk in men will be summarized. Finally, the therapeutic options and their efficacy in male osteoporosis and hypogonadism will be discussed.

Body mass index and the risk of low bone mass-related fractures in women compared with men: A PRISMA-compliant meta-analysis of prospective cohort studies

BACKGROUND

Body mass index (BMI) is inconsistently associated with the progression of low bone mass-related fractures. We conducted a systematic review and meta-analysis to summarize the evidence regarding the relationship between BMI and the risk of fracture in men and women separately. Furthermore, we analyzed the association between BMI and fracture risk in women compared with men.

METHODS

PubMed, EmBase, and the Cochrane Library were searched up to November 2015 to identify prospective cohort studies of low bone mass-related fractures. Prospective cohort studies that reported effect estimates of fracture risk for different BMI categories compared to normal weight were included. Relative risk (RR) and the ratio of relative risk (RRR) were calculated using a random-effect model to measure the relationship between BMI and fracture risk.

RESULTS

We analyzed 37 cohorts (32 articles), which included a total of 506,004 women and 118,372 men; overall, 38,200 incident cases were reported. Overall, a lower BMI was not associated with fracture risk in men (RR: 1.50, 95% confidence interval [CI]: 1.00-2.26; P = 0.051) or women (RR: 1.25, 95% CI: 0.97-1.62; P = 0.083). Although a higher BMI might play a beneficial impact in men (RR: 0.80, 95% CI: 0.69-0.93; P = 0.003), it has little effect in women (RR: 0.91, 95% CI: 0.74-1.11; P = 0.343). In addition, an increase in BMI by 5 kg/m decreased the risk of fractures in men (RR: 0.90, 95% CI: 0.83-0.98; P = 0.017) and women (RR: 0.85, 95% CI: 0.81-0.89; P < 0.001). Finally, there was no evidence of a sex difference in the RR for fractures between participants with different BMI categories compared with those with normal BMI. Finally, gender did not affect the risk of fracture for any category of BMI values.

CONCLUSION

Higher BMI may affect the risk of fractures regardless of the sex. This association may be due to the interaction between the participants' BMI and their bone mass density.

Femoral Neck Bone Mineral Density in Persons Over 50 Years Performing Shiftwork: An Epidemiological Study

OBJECTIVE

Shiftwork has been associated with bone loss due to hormonal fluctuations. Our aim was to assess the femoral neck bone mineral density and content in persons over 50 years performing shiftwork.

METHODS

We performed analysis on the femoral neck bone mineral parameters in persons over age 50 years from the National Health and Nutrition Examination Survey cross-sectional data for 2010 to 2011 in regular and shiftworkers. We also assessed the degree of moderate physical activity and smoking in both groups.

RESULTS

Middle-aged men performing shiftwork had significantly higher total femur bone mineral content (37.33 ± 11.00 vs 34.09 ± 10.45, P = 0.01) and femoral neck bone mineral content (4.57 ± 1.07 vs 4.29 ± 1.0, P = 0.03). This difference was not seen in middle aged women.

CONCLUSIONS

Shiftwork does not seem to affect bone mineral density in those performing moderate physical activity.

Effect of the water fraction isolated from Fructus Ligustri Lucidi extract on bone metabolismviaantagonizing a calcium-sensing receptor in experimental type 1 diabetic rats

Osteoprotective effects of FLL water fraction by potentially regulating vitamin D metabolism and calcium transporters as well as CaSR.

The Impact of Disease and Drugs on Hip Fracture Risk

We report the risks of a comprehensive range of disease and drug categories on hip fracture occurrence using a strict population-based cohort design. Participants included the source population of a Swedish county, aged ≥50 years (n = 117,494) including all incident hip fractures during 1 year (n = 477). The outcome was hospitalization for hip fracture (ICD-10 codes S72.0-S72.2) during 1 year (2009-2010). Exposures included: prevalence of (1) inpatient diseases [International Classification of Diseases (ICD) codes A00-T98 in the National Patient Register 1987-2010] and (2) prescribed drugs dispensed in 2010 or the year prior to fracture. We present age- and sex-standardized risk ratios (RRs), risk differences (RDs) and population attributable risks (PARs) of disease and drug categories in relation to hip fracture risk. All disease categories were associated with increased risk of hip fracture. Largest risk ratios and differences were for mental and behavioral disorders, diseases of the blood and previous fracture (RRs between 2.44 and 3.00; RDs (per 1000 person-years) between 5.0 and 6.9). For specific drugs, strongest associations were seen for antiparkinson (RR 2.32 [95 % CI 1.48-1.65]; RD 5.2 [1.1-9.4]) and antidepressive drugs (RR 1.90 [1.55-2.32]; RD 3.1 [2.0-4.3]). Being prescribed ≥10 drugs during 1 year incurred an increased risk of hip fracture, whereas prescription of cardiovascular drugs or ≤5 drugs did not appear to increase risk. Diseases inferring the greatest PARs included: cardiovascular diseases PAR 22 % (95 % CI 14-29) and previous injuries (PAR 21 % [95 % CI 16-25]; for specific drugs, antidepressants posed the greatest risk (PAR 16 % [95 % CI 12.0-19.3]).

Secondhand Smoke Is an Important Modifiable Risk Factor in Sickle Cell Disease: A Review of the Current Literature and Areas for Future Research

Sickle cell disease (SCD) is an autosomal recessive hemoglobinopathy that causes significant morbidity and mortality related to chronic hemolytic anemia, vaso-occlusion, and resultant end-organ damage. Tobacco smoke exposure (TSE) through secondhand smoke exposure in people with SCD of all ages and through primary smoking in adolescents and adults is associated with significantly increased morbidity, with increased rates of emergency department visits and hospitalizations for painful vaso-occlusive crises and acute chest syndrome (ACS). Secondhand smoke is also associated with pulmonary function abnormalities in children with SCD who are already at risk for pulmonary function abnormalities on the basis of SCD. TSE is emerging as one of the few modifiable risk factors of SCD. This review discusses the current state of the evidence with respect to TSE and SCD morbidity, discusses potential mechanisms, and highlights current gaps in the evidence and future research directions.

Effects of depression and antidepressant medications on hip fracture: A population-based cohort study in Taiwan

This study was conducted to investigate the effects of depression and antidepressant medications on hip fracture. The database of the Taiwan National Health Insurance with medical records of more than 1,000,000 individuals was searched for patients who had hip fracture with or without depression from 1998 to 2009. Patients with the following conditions were excluded: hip fracture due to cancer or traffic accidents, hip fracture that occurred before the diagnosis of depression, and use of antidepressants before the diagnosis of depression. A matched cohort of 139,110 patients was investigated, including 27,822 (17,309 females; 10,513 males) with depression and 111,288 (69,236 females; 42,052 males) without depression (1:4 randomly matched with age, sex, and index date). Among these patients, 232 (158 females and 74 males) had both hip fracture and depression, and 690 (473 females and 217 males) had hip fracture only. The Cox proportional-hazards regression method was used to determine the effect of depression on hip fracture. The hazard ratio (HR) for each clinical parameter was calculated after adjusting for confounders including sex, age, Charlson comorbidity index, urbanization, osteoporosis, and antidepressants. Results showed that patients with major depressive disorder had a 61% higher incidence of hip fracture than those without depression (HR 1.61, 95% confidence interval [CI] 1.19-2.18, P = 0.002). The risk of hip fracture for patients with less severe depressive disorder (dysthymia or depressive disorder, not otherwise specified) was not statistically higher than that of patients with no depression (HR 1.10, 95% CI = 0.91-1.34, P = 0.327). Among the patients with depression, females had a 49% higher incidence for hip fracture than males (HR 1.49, 95% CI 1.30-1.72, P < 0.001). The incidence of hip fracture also increased with age and Charlson comorbidity index scores. Analyses of both all (139,110) patients and only patients (27,822) with depression revealed that antidepressants had no negative impact on the incidence of hip fracture. In conclusion, major depression was found to be a risk factor for hip fracture and that use of antidepressants had no adverse effect on hip fracture in the Taiwanese population.

Genome-Wide Association Study of Bone Mineral Density in Korean Men

Osteoporosis is a medical condition of global concern, with increasing incidence in both sexes. Bone mineral density (BMD), a highly heritable trait, has been proven a useful diagnostic factor in predicting fracture. Because medical information is lacking about male osteoporotic genetics, we conducted a genome-wide association study of BMD in Korean men. With 1,176 participants, we analyzed 4,414,664 single nucleotide polymorphisms (SNPs) after genomic imputation, and identified five SNPs and three loci correlated with bone density and strength. Multivariate linear regression models were applied to adjust for age and body mass index interference. Rs17124500 (p = 6.42 × 10^-7), rs34594869 (p = 6.53 × 10^-7) and rs17124504 (p = 6.53 × 10^-7) in 14q31.3 and rs140155614 (p = 8.64 × 10^-7) in 15q25.1 were significantly associated with lumbar spine BMD (LS-BMD), while rs111822233 (p = 6.35 × 10^-7) was linked with the femur total BMD (FT-BMD). Additionally, we analyzed the relationship between BMD and five genes previously identified in Korean men. Rs61382873 (p = 0.0009) in LRP5, rs9567003 (p = 0.0033) in TNFSF11 and rs9935828 (p = 0.0248) in FOXL1 were observed for LS-BMD. Furthermore, rs33997547 (p = 0.0057) in ZBTB and rs1664496 (p = 0.0012) in MEF2C were found to influence FT-BMD and rs61769193 (p = 0.0114) in ZBTB to influence femur neck BMD. We identified five SNPs and three genomic regions, associated with BMD. The significance of our results lies in the discovery of new loci, while also affirming a previously significant locus, as potential osteoporotic factors in the Korean male population.