TBS result is not affected by lumbar spine osteoarthritis

The effect of lumbar osteoarthritis on bone density and trabecular bone score (TBS) was evaluated cross-sectionally and prospectively in postmenopausal women. Lumbar spine osteoarthritis was graded according to Kellgren and Lawrence grades. Lumbar osteoarthritis was found to increase lumbar spine bone density, but not TBS.

INTRODUCTION

Lumbar osteoarthritis overestimates lumbar bone density (areal bone mineral density (aBMD)). A new texture parameter, the TBS, has been proposed. Calculation of aBMD uses grey level value, while TBS uses grey level variation. Therefore, our hypothesis was that TBS is not influenced by lumbar spine osteoarthritis.

METHODS

Menopausal women participating in osteoporosis and ultrasound (OPUS) study were included. They had an aBMD measurement of the spine and hip at baseline and 6-year visit. TBS was calculated on lumbar spine dual-energy X-ray absorptiometry (DXA) scans in an automated manner. The presence of lumbar osteoarthritis was evaluated on baseline radiographs using Kellgren and Lawrence (K&L) classification. Grades range from 0 to 4. In our study, osteoarthritis was defined by at least K&L grade 2.

RESULTS

This study included 1,254 menopausal women (66.7 ± 7.1 years). Among them, 727 attended the 6-year follow-up visit. Patients with lumbar osteoarthritis had an aBMD higher than those without lumbar osteoarthritis at the lumbar spine, but not at the hip. However, the aBMD significantly increased in all sites with the grade of K&L. In contrast, spine TBS was not different between patients with and without lumbar osteoarthritis (p = 0.70), and it was not correlated with K&L grade. Spine TBS and aBMD at all sites were negatively correlated with age (p < 0.0001). Body mass index was correlated positively with aBMD and negatively with spine TBS (p < 0.0001). The 6-year change of aBMD was significant in the hip and nonsignificant in the lumbar spine. That of TBS was significant, with a 3.3 % decrease (p < 0.0001), independent of K&L grade (p = 0.28).

CONCLUSION

In postmenopausal women, lumbar osteoarthritis leads to an increase in lumbar spine aBMD. In contrast, spine TBS is not affected by lumbar osteoarthritis.

How long should we treat?

Osteoporosis is a chronic disease, for which effective drugs are available. These drugs have reduced the risk of osteoporosis-related fractures in robust trials of 3-5 years duration. There is no evidence of anti-fracture efficacy for treatments of longer duration. The consequences of stopping treatments are very different for the different molecules. Bisphosphonates can be safely discontinued after 3-5 years of treatment if there was optimal adherence and if patients are no longer osteoporotic. This discontinuation cannot be applied in patients with recent fractures or for other treatments. Safety of prolonged treatment is a huge concern which must be managed appropriately. The decision of a prolonged treatment is driven by the underlying risk of fracture. This risk must be assessed regularly in order to share with the patient the benefit-risk ratio of prolonged treatment.

Cost-effectiveness analysis of hip fracture prevention with vitamin D supplementation: a Markov micro-simulation model applied to the French population over 65 years old without previous hip fracture

We performed a cost-effectiveness analysis of four vitamin D supplementation strategies for primary prevention of hip fracture among the elderly population and found that the most cost-effective strategy was screening for vitamin D insufficiency followed by adequate treatment to attain a minimum 25(OH) serum level.

INTRODUCTION

Vitamin D supplementation has a demonstrated ability to reduce the incidence of hip fractures. The efficiency of lifetime supplementation has not yet been assessed in the population over 65 years without previous hip fracture. The objective was to analyze the efficiency of various vitamin D supplementation strategies for that population.

METHODS

A Markov micro-simulation model was built with data extracted from published studies and from the French reimbursement schedule. Four vitamin D supplementation strategies were evaluated on our study population: (1) no treatment, (2) supplementation without any serum level check; (3) supplementation with a serum level check 3 months after initiation and subsequent treatment adaptation; (4) population screening for vitamin D insufficiency followed by treatment based on the vitamin D serum level.

RESULTS

"Treat, then check" and "screen and treat" were two cost-effective strategies and dominated "treat without check" with incremental cost-effectiveness ratios of €5,219/quality-adjusted life-years (QALY) and €9,104/QALY, respectively. The acceptability curves showed that over €6,000/QALY, the "screen and treat" strategy had the greatest probability of being cost-effective, and the "no treatment" strategy would never be cost-effective if society were willing to spend over €8,000/QALY. The sensitivity analysis showed that among all parameters varying within realistic ranges, the cost of vitamin D treatment had the greatest effect and yet remained below the WHO cost-effectiveness thresholds.

CONCLUSIONS

Population screening for vitamin D insufficiency followed by treatment based on the vitamin D serum level is the most cost-effective strategy for preventing hip fracture occurrence in the population over 65 years old.

Adalimumab in patients with hand osteoarthritis refractory to analgesics and NSAIDs: a randomised, multicentre, double-blind, placebo-controlled trial

AIM

To test the efficiency of tumour necrosis factor blockers (adalimumab) in patients with painful refractory (non-responders to analgesics and non-steroidal anti-inflammatory drugs (NSAIDs)) hand osteoarthritis (OA).

METHODS

We performed a randomised, double-blind, placebo-controlled, parallel group, multicentre study. Patients were randomised to: 1/1 adalimumab 40 mg for two subcutaneous injections at a 15-day interval or placebo and monitored for 6 months. The primary outcome was the percentage of patients with an improvement of more than 50% in global pain (Visual Analogue Scale) between week 0 (W0) and week 6 (W6). Secondary outcomes included the number of painful joints, swollen joints, morning stiffness duration, patient and practitioner global assessments, functional indexes for hand OA, and consumption of analgesics. Analysis on the mean primary outcome measure was done on patients who received at least one injection.

RESULTS

99 patients were recruited and 85 patients were randomised. Among them, 37 patients in the placebo group and 41 in the adalimumab group received at least one injection and were evaluated at W6 (n=78) on the main efficacy outcome. Mean age was 62 years, 85% were women, and mean level of pain was 62 mm at W0. At W6, 35.1% in the adalimumab group versus 27.3% in the placebo group had a pain reduction ≥50% (RR 1.12 (95% CI 0.82 to 1.54; p=0.48). There were no statistical differences for all secondary end points. The rate of adverse events was similar in the two groups.

CONCLUSIONS

Adalimumab was not superior to placebo to alleviate pain in patients with hand OA not responding to analgesics and NSAIDs.

TRIALS REGISTRATION NUMBER

NCT00597623.

Vitamin D status of schoolchildren in Northern Algeria, seasonal variations and determinants of vitamin D deficiency

There are no published data on the vitamin D status of children living in North Africa. In 435 healthy Algerian children 5-15 years old, we found that vitamin D insufficiency (serum 25-hydroxyvitamin D (25OHD) <50 nmol/L) was frequent, especially in winter. Low vitamin D status was associated with increased parathyroid hormone (PTH) and leg deformation

INTRODUCTION

As there are no published data on the vitamin D status of children living in North Africa, we evaluated the 25OHD concentration of healthy Algerian children at the end of summer and at the end of winter. As secondary objectives, we studied the various determinants of vitamin D status and the PTH-25OHD relationship in these subjects.

METHODS

Four hundred thirty-five children 5-15 years old were examined and had a blood sample in September 2010. Of them, 408 were sampled again in March 2011.

RESULTS

Median 25OHD concentration in the whole group was 71.4 nmol/L in September and 52.9 nmol/L in March. In September, 58.4, 29.9, and 8.1% had a 25OHD concentration below 75, 50, and 30 nmol/L respectively. In March, these percentages increased to 65.2, 41.4, and 17.4% for the 75, 50, and 30 nmol/L threshold, respectively. In multivariate analysis, older age, darker skin phototype, low daily vitamin D and calcium intake, poor socioeconomic status, and short daily sun exposure remained significantly associated with a 25OHD <50 nmol/L at both visits. In 72 (16.6%) children, genu varum/valgum was present. Compared to the 363 children without leg deformation, they presented more frequently with the risk factors of vitamin D insufficiency. They also had lower 25OHD concentrations and higher PTH and tALP. Serum PTH and 25OHD concentrations were negatively and significantly correlated (r = -0.43; p < 0.001) without a 25OHD threshold above which PTH does not decrease anymore.

CONCLUSION

Despite a sunny environment, vitamin D insufficiency is frequent in healthy Algerian children.

[Perioperative management of atrial fibrillation]

Atrial fibrillation is a frequent complication in the perioperative period. When it appears there is an increased risk of perioperative morbidity due to stroke, thromboembolism, cardiac arrest, myocardial infarction, anticoagulation haemorrhage, and hospital readmissions. The current article focuses on the recommendations for the management of perioperative atrial fibrillation based on the latest Clinical Practice Guidelines on atrial fibrillation by the European Society of Cardiology and the Spanish Society of Cardiology. This article pays special attention to the preoperative management, as well as to the acute perioperative episode. For this reason, the latest recommendations for the control of cardiac frequency, antiarrhythmic treatment and anticoagulation are included.

Denosumab compared with risedronate in postmenopausal women suboptimally adherent to alendronate therapy: efficacy and safety results from a randomized open-label study

Denosumab has been shown to reduce new vertebral, nonvertebral, and hip fractures in postmenopausal women with osteoporosis. In subjects who were treatment-naïve or previously treated with alendronate, denosumab was associated with greater gains in bone mineral density (BMD) and decreases in bone turnover markers when compared with alendronate-treated subjects. This trial was designed to compare the efficacy and safety of denosumab with risedronate over 12 months in postmenopausal women who transitioned from daily or weekly alendronate treatment and were considered to be suboptimally adherent to therapy. In this randomized, open-label study, postmenopausal women aged ≥55 years received denosumab 60 mg subcutaneously every 6 months or risedronate 150 mg orally every month for 12 months. Endpoints included percentage change from baseline in total hip BMD (primary endpoint), femoral neck, and lumbar spine BMD at month 12, and percentage change from baseline in sCTX-1 at months 1 and 6. Safety was also assessed. A total of 870 subjects were randomized (435, risedronate; 435, denosumab) who had a mean (SD) age of 67.7 (6.9) years, mean (SD) BMD T-scores of -1.6 (0.9), -1.9 (0.7), and -2.2 (1.2) at the total hip, femoral neck, and lumbar spine, respectively, and median sCTX-1 of 0.3 ng/mL at baseline. At month 12, denosumab significantly increased BMD compared with risedronate at the total hip (2.0% vs 0.5%), femoral neck (1.4% vs 0%), and lumbar spine (3.4% vs 1.1%; p<0.0001 at all sites). Denosumab significantly decreased sCTX-1 compared with risedronate at month 1 (median change from baseline of -78% vs -17%; p<0.0001) and month 6 (-61% vs -23%; p<0.0001). Overall and serious adverse events were similar between groups. In postmenopausal women who were suboptimally adherent to alendronate therapy, transitioning to denosumab was well tolerated and more effective than risedronate in increasing BMD and reducing bone turnover.

Added value of trabecular bone score over bone mineral density for identification of vertebral fractures in patients with areal bone mineral density in the non-osteoporotic range

Detection of patients with vertebral fracture is similar for areal bone mineral density (aBMD) and trabecular bone score (TBS) in patients with non-vertebral fracture. In non-osteoporotic patients, TBS adds information to lumbar spine aBMD and is related to an index of spine deterioration.

INTRODUCTION

Vertebral fractures (VFs) are more predictive of future fracture than aBMD. The number and severity of VFs are related to microarchitecture deterioration. TBS has been shown to be related to microarchitecture. The study aimed at evaluating TBS in the prediction of the presence and severity of VFs.

METHODS

Patients were selected from a Fracture Liaison Service (FLS): aBMD and vertebral fracture assessment (VFA) were assessed after the fracture, using dual-energy X-ray-absorptiometry (DXA). VFs were classified using Genant's semiquantitative method and severity, using the spinal deformity index (SDI). TBS was obtained after analysis of DXA scans. Performance of TBS and aBMD was assessed using areas under the curves (AUCs).

RESULTS

A total of 362 patients (77.3% women; mean age 74.3 ± 11.7 years) were analysed. Prevalence of VFs was 36.7%, and 189 patients (52.2%) were osteoporotic. Performance of TBS was similar to lumbar spine (LS) aBMD and hip aBMD for the identification of patients with VFs. In the population with aBMD in the non-osteoporotic range (n = 173), AUC of TBS for the discrimination of VFs was higher than the AUC of LS aBMD (0.670 vs 0.541, p = 0.035) but not of hip aBMD; there was a negative correlation between TBS and SDI (r = -0.31; p < 0.0001).

CONCLUSION

Detection of patients with vertebral fracture is similar for aBMD and TBS in patients with non-vertebral fracture. In patients with aBMD in the non-osteoporotic range, TBS adds information to lumbar spine aBMD alone and is related to an index of spine deterioration.

Disease-specific perception of fracture risk and incident fracture rates: GLOW cohort study

Accurate patient risk perception of adverse health events promotes greater autonomy over, and motivation towards, health-related lifestyles.

INTRODUCTION

We compared self-perceived fracture risk and 3-year incident fracture rates in postmenopausal women with a range of morbidities in the Global Longitudinal study of Osteoporosis in Women (GLOW).

METHODS

GLOW is an international cohort study involving 723 physician practices across ten countries (Europe, North America, Australasia); 60,393 women aged ≥55 years completed baseline questionnaires detailing medical history and self-perceived fracture risk. Annual follow-up determined self-reported incident fractures.

RESULTS

In total 2,945/43,832 (6.8%) sustained an incident fracture over 3 years. All morbidities were associated with increased fracture rates, particularly Parkinson's disease (hazard ratio [HR]; 95% confidence interval [CI], 3.89; 2.78-5.44), multiple sclerosis (2.70; 1.90-3.83), cerebrovascular events (2.02; 1.67-2.46), and rheumatoid arthritis (2.15; 1.53-3.04) (all p < 0.001). Most individuals perceived their fracture risk as similar to (46%) or lower than (36%) women of the same age. While increased self-perceived fracture risk was strongly associated with incident fracture rates, only 29% experiencing a fracture perceived their risk as increased. Under-appreciation of fracture risk occurred for all morbidities, including neurological disease, where women with low self-perceived fracture risk had a fracture HR 2.39 (CI 1.74-3.29) compared with women without morbidities.

CONCLUSIONS

Postmenopausal women with morbidities tend to under-appreciate their risk, including in the context of neurological diseases, where fracture rates were highest in this cohort. This has important implications for health education, particularly among women with Parkinson's disease, multiple sclerosis, or cerebrovascular disease.

Impact of systemic treatment of psoriasis on inflammatory parameters and markers of comorbidities and cardiovascular risk: results of a prospective longitudinal observational study

BACKGROUND

Several markers of comorbidities and cardiovascular (CV) risk are disturbed in moderate to severe psoriasis (PsO). The effect of systemic treatments of psoriasis on these markers remains poorly understood.

OBJECTIVES

To study the frequency of disturbance of inflammatory parameters and markers of comorbidities and CV risk associated with moderate to severe PsO and psoriatic arthritis (PsA), and to assess their evolution under systemic treatments.

METHODS

Monocentric prospective study on patients with PsO and PsA starting a systemic treatment for their psoriasis. The following markers were evaluated at baseline (M0), 3 months (M3) and 6 months (M6); weight, fasting blood glucose, blood pressure, uric acid, hepatic steatosis, smoking, lipid, metabolic and inflammatory parameters.

RESULTS

Forty-three patients, 31 PsO and 12 PsA, were included. Forty completed the study. Response to treatment was good, with 71% of the population obtaining a Psoriasis Area and Severity Index (PASI) of 75. All patients had at least one comorbidity, and 45% had two or more. A statistically significant decrease was observed only for inflammatory parameters (C-reactive protein [CRP], P = 0.004) and erythrocyte sedimentation rate (ESR, P = 0.002). We did not observe any correlation between the PASI and CRP (correlation coefficient 0.128, P = 0.438) or ESR (correlation coefficient 0.294, P = 0.069) for responding patients.

CONCLUSIONS

We observed a high frequency of disturbance of inflammatory parameters and markers of comorbidities and CV risk in a population with moderate to severe PsO and PsA, most of which were not detected before. A significant decrease in inflammatory parameters was noted after the introduction of systemic therapy, while other parameters remained unaffected by the treatment, except the weight that increased under biologics therapies.

Robust lossless watermarking based on circular interpretation of bijective transformations for the protection of medical databases

In this paper, we adapt the image lossless watermarking modulation proposed by De Vleeschouwer et al., based on the circular interpretation of bijective modulations, to the protection of medical relational databases. Our scheme modulates the numerical attributes of the database. It is suited for either copyright protection, integrity control or traitor tracing, being robust to most common database attacks, such as the addition and removal of tuples and the modification of attributes' values. Conducted experiments on a medical database of inpatient hospital stay records illustrate the overall performance of our method and its suitability to the requirements of the medical domain.

Hospital burden of vertebral fractures in France: influence of vertebroplasty

We described the whole population of patients hospitalized for vertebral fractures in France in 2009. Only 6.4 % of them were operated by vertebroplasty; these patients were younger and healthier than non-operated patients.

INTRODUCTION

This study aims to describe the burden of vertebral fractures from the 2009 French Hospital National Database in acute care in people aged 60 years and over, with or without vertebroplasty.

METHODS

All stays due to nonmalignant and nontraumatic vertebral fractures as primary cause were selected. Patients' characteristics were described and compared between patients with or without vertebroplasty. The in-patient mortality was compared to the one related to hip and upper humerus fracture in patients hospitalized during the same year.

RESULTS

In 2009, 13,624 patients were hospitalized for vertebral fracture. Men accounted for 29.3 % of cases. Length of stay was 9.6 ± 8.2 days, higher in patients with at least one comorbidity than in patients without (11.2 ± 8.6 and 7.8 ± 7.2 days, respectively). The in-patient mortality was 0.9 %; it was 3.8 and 1.1 % for hip and upper humerus fractures, respectively. Vertebroplasty was performed in 6.4 % of them. Patients with vertebroplasty were younger (mean age of 75 ± 8 versus 79 ± 9 years), had a less duration of stay (7 ± 7.5 versus 9.8 ± 8.2 days), less comorbidities (at least one comorbidity, 45 versus 54 %), and less in-patient mortality (0.1 versus 0.9 %). Rehospitalization for vertebral fracture occurred in 9 and 6 % of the patient with and without vertebroplasty.

CONCLUSION

This is the first French study assessing the national burden of vertebral fractures based on hospital data. In-hospital death rate is lower in patients with vertebroplasty, who are younger and have less comorbidities than the general population with vertebral fractures.