Guideline adherence by physicians for management of glucocorticoid-induced osteoporosis in Japan: a nationwide health insurance claims database study

Risk of fracture due to glucocorticoid-induced osteoporosis (GIO) can be reduced by anti-osteoporosis (OP) medications. The proportion of patients on long-term glucocorticoid therapy who received anti-OP medications according to the GIO management guidelines has increased in recent years, but is still suboptimal.

INTRODUCTION

Adherence of physicians to guidelines for glucocorticoid (GC)-induced osteoporosis (GIO) management is currently unclear. This study aimed to clarify the state of guideline adherence by physicians in Japan and identify factors associated with guideline adherence using a nationwide health insurance claims database (NDBJ).

METHODS

Patients aged ≥ 50 years who were prescribed GC for ≥ 90 days after 180 days without a GC prescription and who were followed up for osteoporosis (OP) management for the subsequent 360 days during the period spanning 2012-2018 were selected from the NDBJ. Guideline adherence was evaluated with the proportion of patients who received OP management as recommended by the Japanese guidelines. Information on previous vertebral and hip fractures, dementia, and polypharmacy was obtained. Factors associated with OP management were evaluated by logistic regression analysis.

RESULTS

A total of 512,296 patients were considered to be at high risk of fracture according to the guidelines. Proportions of patients receiving OP management (BMD testing or anti-OP medications) have increased in recent years. In 2017, 33.7% of men and 55.3% of women received OP management in the initial 90 days of GC therapy. Female sex, previous anti-OP medications, polypharmacy, and higher GC dose were significantly associated with receiving OP management, while dementia showed an inverse association. A prior history of hip fracture, a strong risk factor for future fracture, was not significantly associated with receiving OP management.

CONCLUSIONS

Although guideline adherence by physicians has increased in recent years, it remains suboptimal. Further efforts to improve guideline adherence are necessary.

TRIAL REGISTRATION NUMBER

The present study is not registered.

Estimates of hip fracture incidence in Japan using the National Health Insurance Claim Database in 2012-2015

Using the nationwide health insurance claims database, we found that the age-standardized hip fracture incidence rates in Japan indicated significant increase in males but no significant change in females during 2012-2015. The fracture risk in subjects aged 75-84 years indicated decrease in females but no change in males.

INTRODUCTION

Nationwide registry data on hip fractures have not yet been established in Japan. Using the newly developed National Database of Health Insurance Claims (NDB), which covers the entire Japanese population, we investigated the incidence rates of hip fractures and the associated regional differences. We also assessed the frequency of osteoporosis prescriptions, bone turnover marker (BTM) level, and bone mineral density (BMD) measurements.

METHODS

The annual numbers of hip fractures, osteoporosis prescriptions, and BTM level and BMD measurements by prefecture from 2012 to 2015 were obtained from NDB data. We calculated the standardized claims-data ratio (SCR) in each prefecture.

RESULTS

The age-standardized incidence rates from 2012 to 2015 indicated no significant change in females and significant increase in males (p value for trend; 0.920, 0.002, respectively). The fracture risk decreased in females aged 75-84 years and indicated no increase in females aged 85-89 years during 2012-2015, while the fracture risk indicated no change in males aged 75-84 years and increased in males aged 85-89 years. The frequency of osteoporosis prescriptions, BTM level measurements, and BMD measurements in the general population in the corresponding period increased with statistical or marginal significance in females and males. West-east regional differences were observed in the incidence rates; the highest SCR values in the western prefectures were approximately double the lowest values in the eastern prefectures.

CONCLUSIONS

The age-standardized hip fracture incidence rates indicated no significant change in females and significant increase in males in Japan from 2012 to 2015.

Change of muscle motor-evoked potentials after motor cortex stimulation caused by acute spinal cord injury in cats

The validity of the evoked compound muscle action potential (ECMAP) as an index of spinal cord injury has not been established in neurophysiologic monitoring of motor function, although evoked spinal cord potential (ESCP) has been. In the current study, nine cats were used. After craniotomy, electric stimuli were applied to the motor area. Four cats were given stimulation of various numbers and frequencies, and the other five cats underwent graded compression of the spinal cord, and then ECMAPs and ESCPs were recorded. Three cats were awakened and their motor functions were assessed 3 weeks later. The amplitude of the ESCP never decreased to 60% or less of the control value, even when ECMAPs disappeared. No motor dysfunction was present 3 weeks after the experiment. ECMAP is clinically useful, providing information on impairments of the spinal cord that otherwise would remain undetected.

Effects of coil orientation and magnetic field shield on transcranial magnetic stimulation in cats

To obtain suitable stimulus conditions for transcranial magnetic stimulation, the evoked compound muscle action potential (ECMAP), evoked spinal cord potential (ESCP), and magnetic and electric fields were analyzed in cats with and without the use of a magnetic field shield. Cats were stimulated using a figure 8 magnetic coil placed on the cranium above the motor cortex. The maximum ECMAP amplitude was recorded when the electric current in the coil was in the mediolateral direction, regardless of whether a magnetic shield with a 5 x 5 cm window was used. ECMAP and ESCP thresholds were reduced when magnetic shielding was in place. Due to the edge effect, the strengths of the magnetic and electric fields were highest in the brainstem area, which is an inhomogeneous volume conductor of the cat's cranium. A large induced electric field directed caudally elicited ECMAP and ESCP responses effectively when a magnetic shield with a 5 x 5 cm window was in place.

Intracortical facilitation and inhibition after paired magnetic stimulation in humans under anesthesia

The evoked spinal cord potential (ESCP) and the evoked compound muscle action potential (ECMAP) after paired transcranial magnetic stimulation were recorded simultaneously in eight subjects undergoing spine surgery. The ESCP was composed of a short-latency initial wave (D-wave) followed by later waves (I-waves). The mean conduction velocity of each wave was approximately 60 m/s. The interstimulus interval (ISI) affected the amplitude of both ESCP and ECMAP; the amplitude was inhibited at short ISIs (2 ms and 5 ms), was facilitated at ISI of 10 ms, and was inhibited again at longer ISIs (50 ms, 100 ms and 200 ms). The changes in later I-waves were prominent compared to the stable D-wave. These results suggest that transcranial magnetic stimulation alters the excitability of the motor cortex by affecting synaptic transmission in corticomotor (CM) neurons. The inhibition of the motor cortex at longer ISIs may contribute to a silent period following transcranial magnetic stimulation.

Magnetic-evoked compound muscle action potential neuromonitoring in spine surgery

STUDY DESIGN

Muscle action potentials elicited by paired transcranial magnetic stimulation were recorded during spine surgery in 34 patients. Anesthesia was based on ketamine and fentanyl.

OBJECTIVES

To evaluate the optimal anesthetic regimen to be used for transcranial magnetic stimulation, and to determine the clinical import of magnetic-evoked compound muscle action potentials.

SUMMARY OF BACKGROUND DATA

Muscle action potential by transcranial magnetic stimulation has been difficult to record under general anesthesia. Ketamine is known to not suppress the muscle responses, although no conclusive clinical study has been reported.

METHODS

Paired transcranial magnetic stimulation was delivered as muscle action potentials were recorded from the limb musculature.

RESULTS

Neuromonitoring was reliable in 56% of total cases and in 82% of the recent cases after reducing fentanyl dosage. Paired magnetic stimulation was an excellent facilitation technique for reliable monitoring. At higher dosages, fentanyl and ketamine decreased the reproducibility of the responses.

CONCLUSIONS

Magnetic-evoked compound muscle action potential neuromonitoring is a sensitive and selective motor pathway monitoring method that covers the entire motor pathway, including the white and gray matter of the spinal cord. Ketamine-based anesthesia is a good choice for this purpose.

Central fibrosarcoma of bone. Report of a case

A case of a 46-year-old Japanese male having fibrosarcoma of bone is reported. The tumor developed in the proximal metaphysis of the left femur. During the three years following onset of the disease with symptoms of local pain and mass, the patient was operated on three times (curettage and bone graft, curettage and bone graft with Jwett's nail fixation and disarticulation). The tumor was found to be an intraosseous translucent lesion on x-ray examiation. Histologically, the tumor consisted of compact or loose, atypical spindle cells, producing abundant collagen-fibers without any osteoid, bony or cartilage formation. From the clinical and pathological findings, this case is thought to be a typical central fibrosarcoma of bone.