Osteomalacia in Adults: A Practical Insight for Clinicians

Fragility Fracture: 10 Commandments

Background

Fragility fractures are a major health concern. It is a fracture that occurs from a low-impact event, such as a fall from standing height or less typically due to weakened bones. These fractures are most commonly associated with conditions like osteoporosis, where the bone density is reduced, making the bones more susceptible to get fractured. Fragility fractures often occur in older adults including post-menopausal women and commonly affect areas, such as the hip, spine, and wrist. These fractures reflect the underlying bone fragility, and following first fragility fracture, there is increased risk of getting further fractures. Apart from osteoporosis, the contributing factors have also to be considered like age, gender, nutritional deficiencies, physical activities, and medical conditions like chronic kidney disease. The other risk factors like smoking, and excessive alcohol consumption, and certain medications such as corticosteroids and anti-convulsants like sodium valproate, can overtime result into osteoporosis.

Methods

Fragility fractures basically revolve around the terminal management of osteoporosis and many issues have not been over emphasized. Hence, these 10 commandments have been crafted to focus on the areas which can help prevent fragility fractures or combat those cases who come with a history of fragility fractures.

Results

The ten commandments have crystallized into various headings, including fragility fracture-the risk factors & DEXA, subnormal turnover bone diseases, microbiota & microbiome, inflammaging including obesity, parathyroid, thyroid & testosterone, dilemmas in the management of osteoporosis in younger adults, vitamin D, calcium & albumin, pharmacologic treatment options, associated medications & alternative therapies, and monitoring. High and low turnover bone disease, dysbiosis in gut, and inflammaging are the highlights including therapy and monitoring.

Conclusion

Fragility fracture also known as osteoporotic fracture has significant morbidity and mortality. Management of osteoporosis has been emboldened with the existing basket of both anti-resorptive and anabolic drugs. Safety concerns on long-term use of these drugs are emerging. These ten commandments will help management strategies to concentrate on targeting therapy to persons most "at risk" of getting these fractures.

Analytical interference of Burosumab therapy on intact fibroblast growth factor 23 (iFGF23) measurements using an immunoassay: preliminary evaluation

Our study evaluated the possible interference of Burosumab (human recombinant monoclonal antibody directed against N-terminal domain of FGF23) on the immunoassay of intact FGF23 (iFGF23) with the Liaison XL. The analytical method uses three different antibodies, one of which directed against the N-terminal portion of FGF23. The evaluation of the method accuracy involved the fully automated execution of a dilution test on EDTA plasma from 5 subjects who had not received any monoclonal antibody (mAb), 20 EDTA plasma from patients treated with Burosumab, and 2 EDTA plasma from subjects who had not received any mAb in witch an adequate volume of Burosumab had been added in vitro. One sample with specific diluent (LIAISON® FGF 23) with an adequate volume of Burosumab had been added in vitro. The dilution assay provided highly inaccurate iFGF23 results in samples with therapeutic concentrations of Burosumab and in samples with concentrations below the LoQ (6.5 pg/mL). The addition of Burosumab to the diluent did not produce any analytical interference. Dissociation of iFGF23 from the mAb-target complex in diluted sample could explain the loss of accuracy in the iFGF23 immunoassay using the Liaison XL analyzer. Burosumab could be an interferent in immunoassay procedures of iFGF23.

Osteoporosis in Older Men: Informing Patient Management and Improving Health-Related Outcomes

Osteoporosis has been usually considered a female disease, generally causing more fracture risk and complications in adult and older women compared to older men. While vertebral fractures occur in a small proportion of men during middle age, men generally fracture about 10 years later than women, with significant increases in fracture risk after about age 75. Independent of age, men experiencing fragility fractures have a higher risk of life-threatening events compared to women, but the risk of secondary fragility fracture overlaps between men and women. Often, male osteoporosis recognizes the overlap between secondary causes and primary osteoporosis risk factors. Assessment through physical examination, history, and laboratory tests is recommended, with dual-energy X-ray absorptiometry of bone density being the preferred diagnostic test for osteoporosis in men. A treatment program should include awareness of diet and vitamin D status, fall risk reduction, and pharmaceutical therapy. Medications that are fracture-reducing in older women should also achieve fewer fractures in older men; however, there is a paucity of studies in men with the primary outcome of fracture risk reduction. Most older men with osteoporosis should be treated with oral or intravenous bisphosphonates, denosumab especially when on androgen deprivation therapy, and initial anabolic treatment should be considered for men at very high risk of fracture. This review summarizes the main features of osteoporosis and fragility fractures in men and reports findings from the available pharmacological and non-pharmacological studies conducted in men.

Non-neoplastic bone, joint, and soft tissue pathology: What every pathologist should know

The diagnosis of bone and soft tissue tumors is a skill which requires experience across multiple disciplines while their incidence is small. By contrast, the numbers of patients with non-tumorous diseases of bones, soft tissues, and joints dwarfs primary tumors by several orders of magnitude. The ability to successfully diagnose non-neoplastic diseases requires a knowledge of bone development, structure, remodeling, imaging, and tissue processing. This review summarizes the alterations of bones, joints, and to a lesser extent soft tissues that are encountered in the practice of everyday surgical pathology.

Introduction to Osteoporosis, Osteomalacia, and Fragility Fractures

Background

Osteoporosis is a disease of the bones leading to decreased bone mineral density, leading to fragility fractures. This article is an overview of osteoporosis, osteomalacia and fragility fractures and serves as an introductory article for this special issue on osteoporosis.

Methods

This is a short, comprehensive account of the given conditions with concepts and a review from the recent literature. The authors provide relevant references from the literature in the bibliography. The sections herein have also been deliberated in the meetings of experts of osteoporosis.

Results

An overview of osteoporosis, osteomalacia and fragility fractures is provided, including definitions and summaries of aetiology, pathophysiology, diagnosis, prevention, and management. A detailed account of some of these topics will be provided in subsequent chapters.

Conclusion

Osteoporosis is a silent disease with the potential to cause significant morbidity and mortality if not detected early. It is important to differentiate from and diagnose associated osteomalacia to provide accurate therapy. It is also important to identify the type of fragility fractures and initiate treatment for bone strengthening to prevent subsequent fractures.

Managing psoriatic arthritis in different clinical scenarios

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic, immune-mediated disease characterized by synovio-entheseal inflammation. It is estimated to affect around 30% of patients with psoriasis and significantly reduces patients' physical function and quality of life. There is a growing number of treatment options for PsA, but due to the heterogeneous clinical features of the disease and prevalence of comorbidities, managing PsA can be challenging.

AREAS COVERED

In this article, we review current understanding of the disease and available pharmacological options. Based on published treatment guidelines, emerging evidence and clinical experience, we provide our expert opinion on treatment strategies, taking into consideration the predominant disease domain and the presence of comorbidities, which can impact treatment decisions and clinical outcomes.

EXPERT OPINION

Biological and targeted synthetic disease-modifying agents are dramatically improving the lives of patients with PsA. Biosimilar TNF inhibitors offer a particularly versatile and cost-effective option, whilst newer biologics and targeted synthetic molecules that can be used to treat most domains of psoriatic disease are an attractive alternative to TNF inhibitors. Despite a lack of consensus on treatment sequencing and tapering, it is important that PsA patients, especially those with comorbidities, are looked after by a multidisciplinary team to optimize their care.