Identification and management of patients at increased risk of osteoporotic fracture: outcomes of an ESCEO expert consensus meeting

Osteoporosis represents a significant and increasing healthcare burden in Europe, but most patients at increased risk of fracture do not receive medication, resulting in a large treatment gap. Identification of patients who are at particularly high risk will help clinicians target appropriate treatment more precisely and cost-effectively, and should be the focus of future research.

INTRODUCTION

The purpose of the study was to review data on the identification and treatment of patients with osteoporosis at increased risk of fracture.

METHODS

A working group convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis met to review current data on the epidemiology and burden of osteoporosis and the patterns of medical management throughout Europe.

RESULTS

In Europe in 2010, the cost of managing osteoporosis was estimated at €37 billion and notably the costs of treatment and long-term care of patients with fractures were considerably higher than the costs for pharmacological prevention. Despite the availability of effective treatments, the uptake of osteoporosis therapy is low and declining, in particular for secondary fracture prevention where the risk of a subsequent fracture following a first fracture is high. Consequently, there is a significant treatment gap between those who would benefit from treatment and those who receive it, which urgently needs to be addressed so that the burden of disease can be reduced.

CONCLUSIONS

Implementation of global fracture prevention strategies is a critical need. Future research should focus on identifying specific risk factors for imminent fractures, periods of high fracture risk, patients who are at increased risk of fracture and therapies that are most suited to such high-risk patients and optimal implementation strategies in primary, secondary and tertiary care.

A new primary mobility tool for the visually impaired: A white cane-adaptive mobility device hybrid

This article describes pilot testing of an adaptive mobility device-hybrid (AMD-H) combining properties of two primary mobility tools for people who are blind: the long cane and adaptive mobility devices (AMDs). The long cane is the primary mobility tool used by people who are blind and visually impaired for independent and safe mobility and AMDs are adaptive devices that are often lightweight frames approximately body width in lateral dimension that are simply pushed forward to clear the space in front of a person. The prototype cane built for this study had a wing apparatus that could be folded around the shaft of a cane but when unfolded, deployed two wheeled wings 25 cm (9.8 in) to each side of the canetip. This project explored drop-off and obstacle detection for 6 adults with visual impairment using the deployed AMD-H and a standard long cane. The AMD-H improved obstacle detection overall, and was most effective for the smallest obstacles (2 and 6 inch diameter). The AMD-H cut the average drop off threshold from 1.79 inches (4.55 cm) to .96 inches (2.44 cm). All participants showed a decrease in drop off detection threshold and an increase in detection rate (13.9% overall). For drop offs of 1 in (2.54 cm) and 3 in (7.62 cm), all participants showed large improvements with the AMD-H, ranging from 8.4 to 50%. The larger drop offs of 5 in (12.7 cm) and 7 in (17.8 cm) were well detected by both types of canes.

Post-fracture care: do we need to educate patients rather than doctors? The PREVOST randomized controlled trial

We conducted a multicenter, randomized controlled trial to evaluate the impact of a population-based patient-centered post-fracture care program with a dedicated case manager, PREVention of OSTeoporosis (PREVOST), on appropriate post-fracture osteoporosis management. We showed that, compared to usual care, BMD investigation post-fracture was significantly improved (+20%) by our intervention program.

INTRODUCTION

Our study aims to evaluate the impact of a population-based patient-centered post-fracture care program, PREVOST, on appropriate post-fracture care.

METHODS

Multicenter, randomized controlled trial enrolling 436 women aged 50 to 85 years and attending a French hospital, for a low-energy fracture of the wrist or humerus. Randomization was stratified by age, hospital department, and site of fracture. The intervention was performed by a trained case manager who interacted only with the patients, with repeated oral and written information about fragility fractures and osteoporosis management, and prompting them to visit their primary care physicians. Control group received usual care. The primary outcome was the initiation of an appropriate post-fracture care defined by Bone Mineral Density (BMD) and/or anti-osteoporotic treatment prescription at 6 months.

RESULTS

At 6 months, 53% of women in intervention group initiated a post-fracture care versus 33% for usual care (adjOR 2.35, 95%CI [1.58-3.50], p < 0.001). Post-fracture care was more frequent after wrist than humerus fracture (adjOR 1.93, 95%CI [1.14-3.30], p = 0.015) and decreased with age (adjOR for 10 years increase 0.76, 95%CI [0.61-0.96], p = 0.02). The intervention resulted in BMD prescription in 50% of patients (adjOR 2.10, 95%CI [1.41-3.11], p < 0.001) and in BMD performance in 41% of patients (adjOR 2.12, 95%CI [1.40-3.20], p < 0.001) versus 33 and 25% for usual care, respectively. Having performed a BMD increased treatment prescription; however, only 46% of women with a low BMD requiring a treatment according to the French guidelines received a prescription.

CONCLUSION

A patient-centered care program with a dedicated case manager can significantly improve post-fracture BMD investigation.

Vitamin B12 status in pregnant women and their infants in South India

BACKGROUND/OBJECTIVES

Vitamin B₁₂ deficiency during pregnancy has been associated with increased risk of adverse perinatal outcomes. However, few studies have investigated the burden and determinants of vitamin B₁₂ status in young infants. This study was conducted to determine the associations between maternal and infant vitamin B₁₂ status.

SUBJECTS/METHODS

Pregnant women participating in a vitamin B₁₂ supplementation trial in Bangalore, India, were randomized to receive vitamin B₁₂ (50 μg) or placebo supplementation daily during pregnancy through 6 weeks postpartum. All women received 60 mg of iron and 500 μg of folic acid daily during pregnancy, as per standard of care. This prospective analysis was conducted to determine the associations between maternal vitamin B₁₂ biomarkers (that is, plasma vitamin B₁₂, methylmalonic acid (MMA) and tHcy) during each trimester with infant vitamin B₁₂ status (n=77) at 6 weeks of age.

RESULTS

At baseline (⩽14 weeks of gestation), 51% of mothers were vitamin B₁₂ deficient (vitamin B₁₂<150 pmol/l) and 43% had impaired vitamin B₁₂ status (vitamin B₁₂<150 pmol/l and MMA>0.26 μmol/l); 44% of infants were vitamin B₁₂ deficient at 6 weeks of age. After adjusting for vitamin B₁₂ supplementation, higher vitamin B₁₂ concentrations in each trimester were associated with increased infant vitamin B₁₂ concentrations and lower risk of vitamin B₁₂ deficiency in infants (P<0.05). After adjusting for vitamin B₁₂ supplementation, infants born to women with vitamin B₁₂ deficiency had a twofold greater risk of vitamin B₁₂ deficiency (P<0.01). Higher maternal folate concentrations also predicted lower risk of vitamin B₁₂ deficiency in infants (P<0.05). Impaired maternal vitamin B₁₂ status, which combined both circulating and functional biomarkers, was the single best predictor of infant vitamin B₁₂ status.

CONCLUSIONS

Impaired maternal vitamin B₁₂ status throughout pregnancy predicted higher risk of vitamin B₁₂ deficiency in infants, after adjusting for vitamin B₁₂ supplementation. Future interventions are needed to improve vitamin B₁₂ status periconceptionally, and to ensure optimal vitamin B₁₂ status and health outcomes in pregnant women and their children.

Expression of eukaryotic-like protein in the microbiome of sponges

Eukaryotic-like proteins (ELPs) are classes of proteins that are found in prokaryotes, but have a likely evolutionary origin in eukaryotes. ELPs have been postulated to mediate host-microbiome interactions. Recent work has discovered that prokaryotic symbionts of sponges contain abundant and diverse genes for ELPs, which could modulate interactions with their filter-feeding and phagocytic host. However, the extent to which these ELP genes are actually used and expressed by the symbionts is poorly understood. Here, we use metatranscriptomics to investigate ELP expression in the microbiomes of three different sponges (Cymbastella concentrica, Scopalina sp. and Tedania anhelens). We developed a workflow with optimized rRNA removal and in silico subtraction of host sequences to obtain a reliable symbiont metatranscriptome. This showed that between 1.3% and 2.3% of all symbiont transcripts contain genes for ELPs. Two classes of ELPs (cadherin and tetratricopeptide repeats) were abundantly expressed in the C. concentrica and Scopalina sp. microbiomes, while ankyrin repeat ELPs were predominant in the T. anhelens metatranscriptome. Comparison with transcripts that do not encode ELPs indicated a constitutive expression of ELPs across a range of bacterial and archaeal symbionts. Expressed ELPs also contained domains involved in protein secretion and/or were co-expressed with proteins involved in extracellular transport. This suggests these ELPs are likely exported, which could allow for direct interaction with the sponge. Our study shows that ELP genes in sponge symbionts represent actively expressed functions that could mediate molecular interaction between symbiosis partners.

Increasing Access to Cost Effective Home-Based Rehabilitation for Rural Veteran Stroke Survivors

INTRODUCTION

An estimated 750,000 Americans experience a stroke annually. Most stroke survivors require rehabilitation. Limited access to rehabilitation facilities has a pronounced burden on functional outcomes and quality of life. Robotic devices deliver reproducible therapy without the need for real-time human oversight. This study examined the efficacy of using home-based, telerobotic-assisted devices (Hand and Foot Mentor: HM and FM) to improve functional ability and reduce depression symptoms, while improving access and cost savings associated with rehabilitation.

METHODS

Twenty stroke survivors performed three months of home-based rehabilitation using a robotic device, while a therapist remotely monitored progress. Baseline and end of treatment function and depression symptoms were assessed. Satisfaction with the device and access to therapy were determined using qualitative surveys. Cost analysis was performed to compare home-based, robotic-assisted therapy to clinic-based physical therapy.

RESULTS

Compared to baseline, significant improvement in upper extremity function (30.06%, p= 0.046), clinically significant benefits in gait speed (29.03%), moderate improvement in depressive symptoms (28.44%) and modest improvement in distance walked (30.2%) were observed. Participants indicated satisfaction with the device. Home-based robot therapy expanded access to post-stroke rehabilitation for 35% of the people no longer receiving formal services and increased daily access for the remaining 65%, with a cost savings of $2,352 (64.97%) compared to clinic-based therapy.

CONCLUSION

Stroke survivors made significant clinically meaningful improvements in the use of their impaired extremities using a robotic device in the home. Home-based, robotic therapy reduced costs, while expanding access to a rehabilitation modality for people who would not otherwise have received care.

Waist-to-Height Ratio as an Indicator of High Blood Pressure in Urban Indian School Children

OBJECTIVE

To examine the utility of waist-to-height ratio to identify risk of high blood pressure when compared to body mass index and waist circumference in South Indian urban school children.

DESIGN

Secondary data analysis from a cross-sectional study.

SETTING

Urban schools around Bangalore, India.

PARTICIPANTS

1913 children (58.1% males) aged 6-16 years with no prior history of chronic illness (PEACH study).

METHODS

Height, weight, waist circumference and of blood pressure were measured. Children with blood pressure ?90th percentile of age-, sex-, and height-adjusted standards were labelled as having high blood pressure.

RESULTS

13.9% had a high waist-to-height ratio, 15.1% were overweight /obese and 21.7% had high waist circumference. High obesity indicators were associated with an increased risk of high blood pressure. The adjusted risk ratios (95% CI) of high systolic blood pressure with waist-to-height ratio, body mass index and waist circumference were 2.48 (1.76, 3.47), 2.59 (1.66, 4.04) and 2.38 (1.74, 3.26), respectively. Similar results were seen with high diastolic blood pressure.

CONCLUSION

Obesity indicators, especially waist-to-height ratio due to its ease of measurement, can be useful initial screening tools for risk of high blood pressure in urban Indian school children.

Development of an Overall Water Quality Index (OWQI) for Surface Water in Indian Context

A number of water quality indices based on classification criteria, sub-indices and aggregation function have been developed by the researchers for categorizing the water quality for different uses. In the present study, a general Overall Water Quality Index (OWQI) is developed to classify the surface water into five categories, viz. excellent, good, fair, poor and polluted. For this purpose, the concentration ranges have been defined on the basis of the Indian Standards (IS) and Central Pollution Control Board (CPCB) standards also taking into account other International standards of World Health Organization (WHO) and European Commission (EC). Sixteen parameters are selected based on social and environmental impact and weights are assigned on their relative importance to impact the quality of water. The proposed index improves understanding of water quality issues by integrating complex data and generates a score which describes the status of water quality. The proposed index will be very useful for the water management authorities to maintain good health of surface water resources.

Spectacular improvement in vitamin D status in elderly osteoporotic women: 8-year analysis of an osteoporotic population treated in a dedicated fracture liaison service

In a population of postmenopausal women with a fragility fracture, we found a drastic reduction in the proportion of women with severe (<25 nmol/L) and moderate (25 to 75 nmol/L) hypovitaminosis D, especially from 2009 onwards. These results show that supplementation has been very widely integrated into current practice.

INTRODUCTION

Vitamin D (25(OH)D) is essential for bone health. In institutionalised osteoporotic women, it reduces the risk of fragility fractures. Numerous articles suggesting the possibility of extraosseous effects have generated a growing number of publications and recommendations on more widespread administration, to limit the risks of moderate or severe hypovitaminosis D. We assessed the impact on clinical practice of these recommendations concerning 25(OH)D supplementation in elderly at-risk populations.

METHODS

A total of 1486 postmenopausal osteoporotic women were seen in the context of a fracture liaison service (i.e. a rheumatology consultation following a peripheral fragility fracture), between May 2005 and December 2012. Of these, 1107 had a 25(OH)D assay (femur, n = 520; humerus, n = 207; wrist, n = 380).

RESULTS

The average age of the total population was 76.7 ± 9.9 years, while for women with an available 25(OH)D assay, the average age was 75.1 ± 11.8 years. The average 25(OH)D (nmol/L) level was similar for the three fracture sites: femur, 30 ± 36.2; humerus, 27.5 ± 24; and wrist, 31 ± 26. A drastic reduction in the proportion of women with severe (<25 nmol/L) and moderate (25 to 75 nmol/L) hypovitaminosis D was observed, especially from 2009 onwards, with a mean prevalence of 69 and 30 % respectively before that year and 35 and 52 % thereafter. Conversely, the proportion of women with 25(OH)D at the threshold value of 75 nmol/L increased from 1.2 to 24 %. Overall, mean serum 25(OH)D levels were significantly higher when comparing the two periods 2005-2008 and 2009-1012 (17.6 ± 14.6 and 48.4 ± 39.2 nmol/L, respectively; p < 0.0001).

CONCLUSION

These results show that supplementation has been very widely integrated into current practice. We can expect it to yield beneficial effects in osseous and extraosseous terms in osteoporotic women, particularly the very elderly.