Osteoporosis in men: an Endocrine Society clinical practice guideline

Developing a model Fracture Liaison Service consultation with patients, carers and clinicians: a Delphi survey to inform content of the iFraP complex consultation intervention

Fracture Liaison Services are recommended to deliver best practice in secondary fracture prevention. This modified Delphi survey, as part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) study, provides consensus regarding tasks for clinicians in a model Fracture Liaison Service consultation.

PURPOSE

The clinical consultation is of pivotal importance in addressing barriers to treatment adherence. The aim of this study was to agree to the content of the 'model Fracture Liaison Service (FLS) consultation' within the iFraP (Improving uptake of Fracture Prevention drug Treatments) study.

METHODS

A Delphi survey was co-designed with patients and clinical stakeholders using an evidence synthesis of current guidelines and content from frameworks and theories of shared decision-making, communication and medicine adherence. Patients with osteoporosis and/or fragility fractures, their carers, FLS clinicians and osteoporosis specialists were sent three rounds of the Delphi survey. Participants were presented with potential consultation content and asked to rate their perception of the importance of each statement on a 5-point Likert scale and to suggest new statements (Round 1). Lowest rated statements were removed or amended after Rounds 1 and 2. In Round 3, participants were asked whether each statement was 'essential' and percentage agreement calculated; the study team subsequently determined the threshold for essential content.

RESULTS

Seventy-two, 49 and 52 patients, carers and clinicians responded to Rounds 1, 2 and 3 respectively. One hundred twenty-two statements were considered. By Round 3, consensus was reached, with 81 statements deemed essential within FLS consultations, relating to greeting/introductions; gathering information; considering therapeutic options; eliciting patient perceptions; establishing shared decision-making preferences; sharing information about osteoporosis and treatments; checking understanding/summarising; and signposting next steps.

CONCLUSIONS

This Delphi consensus exercise has summarised for the first time patient/carer and clinician consensus regarding clearly defined tasks for clinicians in a model FLS consultation.

FRAX without BMD can be used to risk-stratify Veterans who recently sustained a low trauma non-vertebral/non-hip fracture

We evaluated the fracture risk assessment tool (FRAX) without bone mineral density (BMD) in predicting treatment recommendations for patients with a recent low trauma fracture other than hip or vertebral. The concordance, sensitivity, and specificity were 75.6%, 67.3%, and 78.2%, respectively. FRAX without BMD can be used after a fracture to expedite treatment.

INTRODUCTION

The objective of this study was to evaluate the performance of the fracture risk assessment tool (FRAX) without bone mineral density (BMD) in predicting treatment recommendations for patients who recently sustained a low trauma fracture other than hip or vertebral.

METHODS

We utilized a clinical database established by the Fracture Liaison Service at the Durham Veterans Affairs Medical Center to identify male and female Veterans age ≥ 50 years who sustained a low trauma non-hip/non-vertebral fracture and underwent dual-energy x-ray absorptiometry (DXA) between October 2013 and April 2018. FRAX without BMD (FRAX-BMI) and FRAX with BMD (FRAX-BMD) were calculated for the 229 patients identified, and whether or not they met the National Osteoporosis Foundation (NOF) guideline treatment thresholds was compared.

RESULTS

There were 55 (24.0%) patients that met criteria for treatment based on NOF guideline established FRAX-BMD thresholds including 27 (11.8%) patients with osteoporosis by DXA. The concordance of FRAX-BMI in predicting treatment recommendations was 75.6% with a sensitivity of 67.3% and a specificity of 78.2%. The area under the curve (AUC) of FRAX-BMI hip fracture risk was 0.79. Assessment/treatment thresholds for hip fracture risk of 1% < FRAX-BMI < 4% were proposed to maximize sensitivity and specificity.

CONCLUSION

Among patients who sustained a low trauma non-hip/non-vertebral fracture, FRAX-BMI can be used to stratify risk and identify high-risk patients who could be treated without DXA, low-risk patients who may not need treatment, and intermediate-risk patients to undergo DXA testing.

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.

Delivering fracture prevention services to rural US veterans through telemedicine: a process evaluation

An informatics-driven population bone health clinic was implemented to identify, screen, and treat rural US Veterans at risk for osteoporosis. We report the results of our implementation process evaluation which demonstrated BHT to be a feasible telehealth model for delivering preventative osteoporosis services in this setting.

PURPOSE

An established and growing quality gap in osteoporosis evaluation and treatment of at-risk patients has yet to be met with corresponding clinical care models addressing osteoporosis primary prevention. The rural bone health tea m (BHT) was implemented to identify, screen, and treat rural Veterans lacking evidence of bone health care and we conducted a process evaluation to understand BHT implementation feasibility.

METHODS

For this evaluation, we defined the primary outcome as the number of Veterans evaluated with DXA and a secondary outcome as the number of Veterans who initiated prescription therapy to reduce fracture risk. Outcomes were measured over a 15-month period and analyzed descriptively. Qualitative data to understand successful implementation were collected concurrently by conducting interviews with clinical personnel interacting with BHT and BHT staff and observations of BHT implementation processes at three site visits using the Promoting Action on Research Implementation in Health Services (PARIHS) framework.

RESULTS

Of 4500 at-risk, rural Veterans offered osteoporosis screening, 1081 (24%) completed screening, and of these, 37% had normal bone density, 48% osteopenia, and 15% osteoporosis. Among Veterans with pharmacotherapy indications, 90% initiated therapy. Qualitative analyses identified barriers of rural geography, rural population characteristics, and the infrastructural resource requirement. Data infrastructure, evidence base for care delivery, stakeholder buy-in, formal and informal facilitator engagement, and focus on teamwork were identified as facilitators of implementation success.

CONCLUSION

The BHT is a feasible population telehealth model for delivering preventative osteoporosis care to rural Veterans.

Milk proteins and their derived peptides on bone health: Biological functions, mechanisms, and prospects

Bone is a dynamic organ under constant metabolism (or remodeling), where a delicate balance between bone resorption and bone formation is maintained. Disruption of this coordinated bone remodeling results in bone diseases, such as osteoporosis, the most common bone disorder characterized by decreased bone mineral density and microarchitectural deterioration. Epidemiological and clinical evidence support that consumption of dairy products is beneficial for bone health; this benefit is often attributed to the presence of calcium, the physiological contributions of milk proteins on bone metabolism, however, are underestimated. Emerging evidence highlighted that not only milk proteins (including individual milk proteins) but also their derived peptides positively regulate bone remodeling and attenuate bone loss, via the regulation of cellular markers and signaling of osteoblasts and osteoclasts. This article aims to review current knowledge about the roles of milk proteins, with an emphasis on individual milk proteins, bioactive peptides derived from milk proteins, and effect of milk processing in particular fermentation, on bone metabolism, to highlight the potential uses of milk proteins in the prevention and treatment of osteoporosis, and, to discuss the knowledge gap and to recommend future research directions.

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.

Gender Differences in Osteoporosis: A Single-Center Observational Study

Purpose

Osteoporosis affects more than 200 million people worldwide: its prevalence increases with age and is actually growing due to the constant population aging. Women are at greater risk than men, but in recent years it has become increasingly evident that osteoporosis represents a significantly important problem also for men. However, osteoporosis in men is still poorly studied, underdiagnosed and inadequately treated.

Materials and Methods

We conducted an observational study to identify any gender disparities in osteoporosis screening. For this purpose we observed people consecutively admitted at our Outpatient Service for the Diagnosis of Osteoporosis during the last 3 years. Patients underwent clinical and laboratory assessment and bone mineral density (BMD) measurements by dual-energy X-ray absorptiometry. Bone turnover serum markers have been evaluated and stratified according to gender.

Results

Out of 3,752 patients, 2,376 subjects who met the inclusion criteria were identified. As expected, the great majority (94.5%) of the screened subjects were women and only 5.4% were men. Women exhibited lower BMD compared to men (T-score values: −2.33±1.14 vs. −1.31±1.55; p<0.001), whereas the prevalence of fractures in osteoporotic men was significantly higher (50% vs. 31%; p<0.001). Women had lower vitamin D and higher bone remodeling markers compared to men. Secondary osteoporosis was more frequent in men (66.67%) than in women (20.83%) and the calculated risk for hip fractures was higher in osteoporotic men compared to women (11.47±10.62 vs. 6.87±7.73; p<0.001).

Conclusions

Here we highlighted that men are under-screened for osteoporosis and exhibit secondary osteoporosis more frequently than women.

Accelerated Development With Increased Bone Mass and Skeletal Response to Loading Suggest Receptor Activity Modifying Protein-3 as a Bone Anabolic Target

Knockout technologies provide insights into physiological roles of genes. Studies initiated into endocrinology of heteromeric G protein-coupled receptors included deletion of receptor activity modifying protein-3, an accessory protein that alters ligand selectivity of calcitonin and calcitonin-like receptors. Initially, deletion of Ramp3^-/- appeared phenotypically silent, but it has emerged that mice have a high bone mass phenotype, and more subtle alterations to angiogenesis, amylin homeostasis, and a small proportion of the effects of adrenomedullin on cardiovascular and lymphatic systems. Here we explore in detail, effects of Ramp3^-/- deletion on skeletal growth/development, bone mass and response of bone to mechanical loading mimicking exercise. Mouse pups lacking RAMP3 are healthy and viable, having accelerated development of the skeleton as assessed by degree of mineralisation of specific bones, and by microCT measurements. Specifically, we observed that neonates and young mice have increased bone volume and mineralisation in hindlimbs and vertebrae and increased thickness of bone trabeculae. These changes are associated with increased osteoblast numbers and bone apposition rate in Ramp3^-/- mice, and increased cell proliferation in epiphyseal growth plates. Effects persist for some weeks after birth, but differences in gross bone mass between RAMP3 and WT mice lose significance in older animals although architectural differences persist. Responses of bones of 17-week old mice to mechanical loading that mimics effects of vigorous exercise is increased significantly in Ramp3^-/- mice by 30% compared with WT control mice. Studies on cultured osteoblasts from Ramp3^-/- mice indicate interactions between mRNA expression of RAMPs1 and 3, but not RAMP2 and 3. Our preliminary data shows that Ramp3^-/- osteoblasts had increased expression β-catenin, a component of the canonical Wnt signalling pathway known to regulate skeletal homeostasis and mechanosensitivity. Given interactions of RAMPs with both calcitonin and calcitonin-like receptors to alter ligand selectivity, and with other GPCRs to change trafficking or ligand bias, it is not clear whether the bone phenotype of Ramp3^-/- mice is due to alterations in signalling mediated by one or more GPCRS. However, as antagonists of RAMP-interacting receptors are growing in availability, there appears the likelihood that manipulation of the RAMP3 signalling system could provide anabolic effects therapeutically.

Role of Dkk2 in the Muscle/bone Interaction of Androgen-Deficient Mice

Androgen deficiency is known to cause both osteoporosis and sarcopenia. Myokines, humoral factors secreted from the skeletal muscles, have recently been getting attention as the key factors related to the interactions between muscle and bone. Dickkopf (Dkk) 2 is known as an inhibitor of canonical Wnt/β-catenin signaling, and Wnt/β-catenin signaling is crucial for the maintenance of muscle and bone. The present study was therefore performed to investigate the roles of Dkk2 in the alterations of muscle and bone of androgen-deficient mice with orchidectomy (ORX). ORX significantly enhanced Dkk2 mRNA levels, but not other Dkks and secreted frizzled related proteins, in the soleus muscles of mice. Moreover, ORX enhanced serum Dkk2 levels, but not Dkk2 mRNA levels in the tibial bone tissues, the white adipose tissues and liver of mice. In simple regression analyses, serum Dkk2 levels were negatively related to trabecular bone mineral density at the tibias in mice employed in the experiments. In vitro experiments, testosterone suppressed Dkk2 mRNA levels in mouse muscle C2C12 cells. In conclusion, we showed that androgen deficiency enhances Dkk2 expression and secretion in the muscles of mice. Dkk2 might be involved in androgen deficiency-induced muscle wasting and osteopenia as a myokine linking muscle to bone.

Hypogonadism and bone health in men with HIV

The advent of new classes of antiretroviral drugs has improved the survival of people with HIV, and several ageing-related conditions, including hypogonadism and osteoporosis, have emerged. However, both are silent conditions, and are underestimated, underdiagnosed, and not adequately treated. Several factors, including the effects of the virus, antiretroviral therapy, lifestyle factors, and comorbidities, contribute to testicular dysfunction, which in turn has important effects on bone health. The prevalence of hypogonadism is approximately 20% among men with HIV, but extreme variability in the laboratory and clinical assessment of hypogonadism is reported. The prevalence of osteoporosis is 10-30%, but the poor quality of most studies does not allow definitive conclusions on clinical management. Nonetheless, the early and detailed evaluation of gonadal function and bone health is crucial for improving the quality of life of men with HIV.

Cost-effectiveness of Screening for Osteoporosis in Older Men With a History of Falls

Importance

Falls and osteoporosis share the potential clinical end point of fractures among older patients. To date, few fall prevention guidelines incorporate screening for osteoporosis to reduce fall-related fractures.

Objective

To assess the cost-effectiveness of screening for osteoporosis using dual-energy x-ray absorptiometry (DXA) followed by osteoporosis treatment in older men with a history of falls.

Design, Setting, and Participants

In this economic evaluation, a Markov model was developed to simulate the incidence of major osteoporotic fractures in a hypothetical cohort of community-dwelling men aged 65 years who had fallen at least once in the past year. Data sources included literature published from January 1, 1946, to July 31, 2020. The model adopted a societal perspective, a lifetime horizon, a 1-year cycle length, and a discount rate of 3% per year for both health benefits and costs. The analysis was designed and conducted from October 1, 2019, to September 30, 2020.

Interventions

Screening with DXA followed by treatment for men diagnosed with osteoporosis compared with usual care.

Main Outcomes and Measures

Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained.

Results

Among the hypothetical cohort of men aged 65 years, the screening strategy had an ICER of $33 169/QALY gained and was preferred over usual care at the willingness-to-pay threshold of $100 000/QALY gained. The number needed to screen to prevent 1 hip fracture was 1876; to prevent 1 major osteoporotic fracture, 746. The screening strategy would become more effective and less costly than usual care for men 77 years and older. The ICER for the screening strategy did not substantially change across a wide range of assumptions tested in all other deterministic sensitivity analyses. At a willingness-to-pay threshold of $50 000/QALY gained, screening was cost-effective in 56.0% of simulations; at $100 000/QALY gained, 90.8% of simulations; and at $200 000/QALY gained, 99.6% of simulations.

Conclusions and Relevance

These findings suggest that for older men who have fallen at least once in the past year, screening with DXA followed by treatment for those diagnosed with osteoporosis is a cost-effective use of resources. Fall history could be a useful cue to trigger assessment for osteoporosis in men.

Kallman syndrome and central non-obstructive azoospermia

The understanding of male factors of infertility has grown exponentially in the past ten years. While clear guidelines for obstructive azoospermia have been developed, management of non-obstructive azoospermia has lagged. Specifically, management of Kallmann Syndrome and central non-obstructive azoospermia has been limited by a lack of understanding of the molecular pathogenesis and investigational trials exploring the best option for management and fertility in these patients. This review aims to summarize our current understanding of the causes of central hypogonadotropic hypogonadism with a focus on genetic etiologies while also discussing options that endocrinologists and urologists can utilize to successfully treat this group of infertile men.

Understanding Osteoporosis Screening Practices in Men: A Nationwide Physician Survey

OBJECTIVE

To understand osteoporosis screening practices, particularly in men, by a diverse cohort of physicians, including primary care physicians, endocrinologists, and geriatricians.

METHODS

We surveyed randomly selected members of the American Academy of Family Practice, Endocrine Society, and American Geriatrics Society. Respondents were asked to rate how often they would screen for osteoporosis in four different clinical scenarios by ordering a bone density scan. Multivariable logistic regression analyses were conducted to determine factors associated with offering osteoporosis screening in men in each clinical scenario. Physicians were also asked to note factors that would lead to osteoporosis screening in men.

RESULTS

Response rate was 63% (359/566). While 90% respondents reported that they would always or frequently screen for osteoporosis in a 65-year-old post-menopausal woman, only 22% reported they would screen a 74-year-old man with no significant past medical history. Endocrinologists were more likely to screen a 74-year-old man compared to primary care physicians (odds ratio, 2.32; 95% confidence interval, 1.10 to 4.88). In addition to chronic steroid use (94%), history of nontraumatic fractures (88%), and androgen-deprivation therapy for prostate cancer (82%), more than half the physicians reported suppressive doses of thyroid hormone (64%) and history of falls (52%) as factors leading to screening for osteoporosis in men.

CONCLUSIONS

Our survey results highlight heterogeneity in osteoporosis screening in men, with underscreening in some scenarios compared to women, and identify factors that lead to screening in men. These findings can help design interventions to improve osteoporosis screening in men.

Molecular Mechanisms and Emerging Therapeutics for Osteoporosis

Osteoporosis is the most common chronic metabolic bone disease. It has been estimated that more than 10 million people in the United States and 200 million men and women worldwide have osteoporosis. Given that the aging population is rapidly increasing in many countries, osteoporosis could become a global challenge with an impact on the quality of life of the affected individuals. Osteoporosis can be defined as a condition characterized by low bone density and increased risk of fractures due to the deterioration of the bone architecture. Thus, the major goal of treatment is to reduce the risk for fractures. There are several treatment options, mostly medications that can control disease progression in risk groups, such as postmenopausal women and elderly men. Recent studies on the basic molecular mechanisms and clinical implications of osteoporosis have identified novel therapeutic targets. Emerging therapies targeting novel disease mechanisms could provide powerful approaches for osteoporosis management in the future. Here, we review the etiology of osteoporosis and the molecular mechanism of bone remodeling, present current pharmacological options, and discuss emerging therapies targeting novel mechanisms, investigational treatments, and new promising therapeutic approaches.

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.

Bone Health and Osteoporosis Prevention and Treatment

Postmenopausal osteoporosis is a common condition and is associated with increased risk of fracture, including hip and vertebral fractures that in turn can have devastating consequences on morbidity and mortality. In this article, we review the pathogenesis and diagnostic approach to postmenopausal osteoporosis. We review available nonpharmacologic and pharmacologic therapies and we discuss their clinical efficacy and complications, with a detailed discussion of atypical femur fractures and osteonecrosis of the jaw.

The Impact of Sex and Gender on the Multidisciplinary Management of Care for Persons With Parkinson's Disease

The impact of sex and gender on disease incidence, progression, and provision of care has gained increasing attention in many areas of medicine. Biological factors–sex–and sociocultural and behavioral factors–gender–greatly impact on health and disease. While sex can modulate disease progression and response to therapy, gender can influence patient-provider communication, non-pharmacological disease management, and need for assistance. Sex and gender issues are especially relevant in chronic progressive diseases, such as Parkinson's disease (PD), because affected patients require multidisciplinary care for prolonged periods of time. In this perspective paper, we draw from evidence in the field of PD and various other areas of medicine to address how sex and gender could impact PD care provision. We highlight examples for which differences have been reported and formulate research topics and considerations on how to optimize the multidisciplinary care of persons with PD.

Bone Mineral Density and Body Composition in Males with Motor Neuron Disease: A Study from Teaching Hospital in Southern Part of India

Background

Osteoporosis and sarcopenia are important aspects of motor neuron disease (MND). Individuals with amyotrophic lateral sclerosis (MND-ALS) have an increased risk of falls and fractures. Currently, the standard of care does not involve a routine assessment of bone mineral density (BMD) and body composition in these patients. We aimed to assess BMD, bone mineral parameters and body composition in men with MND and compared them with healthy controls.

Methods

Consecutive males between 50 and 80 years of age diagnosed as MND-ALS by revised El Escorial criteria and able to walk unassisted attending Neurology outpatient clinic were recruited into the study. Age, gender and body mass index (BMI) matched healthy controls were recruited from the local community. BMD and body composition were assessed by dual-energy x-ray absorptiometry (DXA). Bone mineral parameters and bone turnover markers (BTMs) were also assessed in them.

Results

A total of 30 subjects with MND-ALS and 33 controls were recruited. The mean age (years) was 59.2 in cases and 61.2 in controls. The mean BMD (g/cm²) between the two groups was similar; however, BTMs were significantly higher in the MND group (P < 0.05). Subjects with MND-ALS had significantly lower mean appendicular lean mass (ALM) (19.9 versus 22.4 kg; P = 0.007) and ALM corrected for BMI than the healthy control group (0.858 versus 0.934 kg/kg/m²; P = 0.034). Sarcopenic obesity (Percentage fat mass >27% + ALM/BMI <0.786 kg/kg/m²) was more prevalent in MND-ALS compared to controls (44.5% versus 16.7%; P = 0.03).

Conclusion

Although BMD was not significantly different between subjects with MND-ALS and healthy controls, BTMs were significantly higher in the MND group indicating a high bone turnover state. Sarcopenia and sarcopenic obesity were also more in MND-ALS group than controls. Routine assessment for bone health parameters and body composition indices may be included in management of the patients with MND.

Risk of fracture incidence in prostate cancer survivors: a nationwide cohort study in South Korea

PURPOSE

We analyzed the risk of fracture in prostate cancer (PC) survivors compared to that in the general population in South Korea and according to the primary treatment.

METHODS

From 2007 to 2013, a total of 41,733 PC survivors newly diagnosed with PC in South Korea were identified and matched to non-cancer controls. Cox proportional hazards regression analysis was performed to determine the relative risk of fracture.

RESULTS

Compared to the matched controls, PC survivors had a higher risk of fracture (adjusted hazard ratio (aHR) 1.39; 95% confidence interval (CI) 1.33-1.45). Compared to the matched controls, the active surveillance/watchful waiting and radiotherapy group showed a similar risk of fracture (aHR 1.08; 95% CI 0.98-1.20, and aHR 1.04; 95% CI 0.63-1.73, respectively). PC survivors who underwent surgery showed a lower risk of fracture (aHR 0.89; 95% CI 0.82-0.96), while those who underwent surgery + androgen deprivation therapy (ADT) (aHR 1.41; 95% CI 1.26-1.57), radiotherapy + ADT (aHR 1.86; 95% CI 1.50-2.32), and only ADT (aHR 1.92; 95% CI 1.82-2.02) showed a higher risk of fracture than the control group.

CONCLUSION

The risk of fracture differed according to the primary treatment method for PC; survivors who underwent surgery had a lower risk of fracture compared to that of the general population. However, PC survivors treated with ADT showed a higher risk of fracture than the other PC treatment groups or the general population. Therefore, more attention and preventive bone care are required for PC survivors who receive ADT.

Low bone mineral density is associated with hypogonadism and cranial irradiation in male childhood cancer survivors

We investigated if bone mineral density was related to testosterone deficiency and/or previous cancer treatment in men who were childhood cancer survivors. Men with untreated testosterone deficiency or previous treatment with cranial irradiation were at increased risk of impaired bone health. Prevention of osteoporosis should be considered in their follow-up.

INTRODUCTION

Childhood cancer survivors (CCS) are at increased risk of hypogonadism. Reduced bone mineral density (BMD) has been reported in CCS but it is unclear whether this is due to hypogonadism or a direct effect of cancer therapy. This study investigated BMD in CCS, and association with hypogonadism, previous treatment and cancer type.

METHODS

Investigation of 125 CCS (median age 33.7 at inclusion; 9.6 at diagnosis) and 125 age-matched population controls. Serum testosterone and luteinizing hormone were assayed and BMD at total hip and lumbar spine L1-L4 measured. The mean difference in BMD (g/cm²; 95% CI) between CCS and controls was analysed. Odds ratios (OR; 95% CI) for low BMD were also calculated.

RESULTS

Overall, BMD in the CCS cohort did not significantly differ from controls. However, compared with eugonadal CCS, the CCS with untreated hypogonadism had lower BMD at the hip (mean difference - 0.139 (- 0.210; - 0.067); p < 0.001) and spine (- 0.102 (- 0.174; - 0.030); p = 0.006). They also had a higher risk of low hip BMD (OR 4.1 (1.3; 14); p = 0.018). CCS treated with cranial irradiation also had lower BMD (hip - 0.076 (- 0.133; - 0.019); p = 0.009; spine - 0.071 (- 0.124; - 0.018); p = 0.009) compared with controls. The latter associations remained statistically significant after adjustment for hypogonadism.

CONCLUSIONS

CCS with hypogonadism or previously treated with cranial irradiation are at increased risk of impaired bone health. Prevention of osteoporosis should be considered as an important part in future follow-up of these men.

Late-onset Hypogonadism: Bone health

BACKGROUND

Bone health is underdiagnosed and undermanaged in men. Bone loss occurs in men with hypogonadism and in aging men. Thus, patients with a diagnosis of late-onset hypogonadism (LOH) are at risk of osteoporosis and osteoporotic fractures.

OBJECTIVES

To provide an update on research data and clinical implications regarding bone health in men with LOH by reviewing literature articles on this issue.

MATERIALS AND METHODS

A thorough search of listed publications in PubMed on bone health in older men with hypogonadism was performed, and other articles derived from these publications were further identified.

RESULTS

Late-onset Hypogonadism may be associated with reduced bone mineral density (BMD). In a pathophysiological perspective, the detrimental effects of testosterone (T) deficiency on BMD are partly ascribed to relative estrogen deficiency and both serum T and serum estradiol (E2) need to be above 200 ng/dL and 20 pg/mL to prevent bone loss. The effects of exogenous T on BMD are controversial, but most of the studies confirm that testosterone replacement therapy (TRT) increases BMD and prevents further bone loss in men with hypogonadism. No data are available on TRT and the prevention of fractures.

DISCUSSION AND CONCLUSION

In men with documented LOH, a specific clinical workup should be addressed to the diagnosis of osteoporosis in order to program subsequent follow-up and consider specific bone active therapy. TRT should be started according to guidelines of male hypogonadism while keeping in mind that it may also have positive effects also on bone health in men with LOH.

Conditional Knockout of PKC-δ in Osteoclasts Favors Bone Mass Accrual in Males Due to Decreased Osteoclast Function

Protein kinase C delta (PKC-δ) functions as an important regulator in bone metabolism. However, the precise involvement of PKC-δ in the regulation of osteoclasts remains elusive. We generated an osteoclast specific PKC-δ knockout mouse strain to investigate the function of PKC-δ in osteoclast biology. Bone phenotype was investigated using microcomputed tomography. Osteoclast and osteoblast parameters were assessed using bone histomorphometry, and analysis of osteoclast formation and function with osteoclastogensis and hydroxyapatite resorption assays. The molecular mechanisms by which PKC-δ regulated osteoclast function were dissected by Western Blotting, TUNEL assay, transfection and transcriptome sequencing. We found that ablation of PKC-δ in osteoclasts resulted in an increase in trabecular and cortical bone volume in male mice, however, the bone mass phenotype was not observed in female mice. This was accompanied by decreased osteoclast number and surface, and Cathepsin-K protein levels in vivo, as well as decreased osteoclast formation and resorption in vitro in a male-specific manner. PKC-δ regulated androgen receptor transcription by binding to its promoter, moreover, PKC-δ conditional knockout did not increase osteoclast apoptosis but increased MAPK signaling and enhanced androgen receptor transcription and expression, finally leding to significant alterations in gene expression and signaling changes related to extracellular matrix proteins specifically in male mice. In conclusion, PKC-δ plays an important role in osteoclast formation and function in a male-specific manner. Our work reveals a previously unknown target for treatment of gender-related bone diseases.

Primary osteoporosis in men: an unmet medical need

Osteoporosis is a skeletal disease characterized by loss of bone strength and increased risk of fractures. Even though fracture prevalence is higher in women, fractures also constitute a significant public health issue in older men. Men are screened less and more frequently undertreated than female patients. It is the goal of this review, to summarize updated information about the current understanding of pathophysiology and clinical aspects of diagnosis and treatment of osteoporosis in men.

A Chinese Cross-Sectional Study on Symptoms in Aging Males: Prevalence and Associated Factors

The Aging Male Symptoms (AMS) scale is a questionnaire designed for assessing health-related quality of life and aging-related symptoms in men. Additional knowledge of the severity of aging symptoms in males revealed by high AMS scores and the factors associated with it in the Chinese population is required. A nationally representative prevalence and risk factor estimate of AMS scores was performed to identify the associated factors for AMS severity in China. Men aged between 35 and 70 years were recruited at 33 study centers in 21 provinces, 4 municipalities, and 4 autonomous regions. The prevalence of high AMS scores and its association with demographic, anatomical, lifestyle, and clinical variables were evaluated. Chi-square tests and logistic regression models were used for analysis. Odds ratios (ORs) and 95% confidence intervals were calculated. In this study, 918 of 9,164 (10%, p < .001) men aged between 35 and 70 years, had AMS scores ≥50. Univariate and multivariable analyses showed that an age of >40 years, poor marital relations, type 2 diabetes mellitus (T2DM), history of fracture, and smoking ≥25 cigarettes per day were the major factors that were associated with the severity of AMS (OR ≥2; p < .05). Hypertension, low income, a low education level, alcohol consumption, lack of exercise, and a waist-to-hip ratio ≥0.9 were also moderately associated with AMS severity (OR 1-2; p < .05). The current study revealed the nationally representative prevalence of severe AMS scores in Chinese men and the factors associated with severe AMS. Antiaging intervention studies should target men with specific associated factors.

U-Shaped Association of Plasma Testosterone, and no Association of Plasma Estradiol, with Incidence of Fractures in Men

PURPOSE

Whether androgens, distinct from estrogen, maintain bone health during male aging has implications for understanding osteoporosis. We assessed associations of different sex hormones with incidence of any bone fracture or hip fracture in older men.

PARTICIPANTS AND METHODS

Analysis of 3307 community-dwelling men aged 76.8 ± 3.5 years, median follow-up period of 10.6 years. Plasma testosterone (T), dihydrotestosterone (DHT), and estradiol (E2) assayed by mass spectrometry, sex hormone-binding globulin (SHBG), and luteinizing hormone (LH) using immunoassay. Incident fractures determined via data linkage. We analyzed probability of fracture and performed Cox regression adjusted for age, medical comorbidities, and frailty.

RESULTS

Incident fractures occurred in 330 men, including 144 hip fractures. Probability plots suggested nonlinear relationships between hormones and risk of any fracture and hip fracture, with higher risk at lower and higher plasma T, lower E2, higher SHBG, and higher LH. In fully adjusted models, there was a U-shaped association of plasma T with incidence of any fracture (Quartile 2 [Q2] versus Q1: fully adjusted hazard ratio [HR] = 0.69, 95% confidence interval [CI] 0.51-0.94, P = .020; Q3: HR 0.59, 95% CI 0.42-0.83, P = .002) and hip fracture (Q2 versus Q1: HR 0.60, 95% CI 0.37-0.93, P = .043; Q3: HR 0.52, 95% CI 0.31-0.88, P = .015). DHT, E2, and LH were not associated with fracture. Higher SHBG was associated with hip fracture (Q4 versus Q1: HR 1.76, 95% CI 1.05-2.96, P = .033).

CONCLUSIONS

Midrange plasma T was associated with lower incidence of any fracture and hip fracture, and higher SHBG with increased risk of hip fracture. Circulating androgen rather than estrogen represents a biomarker for hormone effects on bone driving fracture risk.

Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition

Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fractureamong people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, andsubcutaneous pharmacotherapies are efficaciousandcanreduce risk of future fracture.Patientsneededucation,however, about thebenefitsandrisks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive butmay be beneficial for selected patients at high risk.Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the earlypost-fractureperiod,prompt treatment is recommended.Adequate dietary or supplemental vitaminDand calciumintake shouldbe assured. Individuals beingtreatedfor osteoporosis shouldbe reevaluated for fracture risk routinely, includingvia patienteducationabout osteoporosisandfracturesandmonitoringfor adverse treatment effects.Patients shouldbestronglyencouraged to avoid tobacco, consume alcohol inmoderation atmost, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease).

Clinical Advances in Sex- and Gender-Informed Medicine to Improve the Health of All: A Review

IMPORTANCE

Biological sex and sociocultural gender represent major sources of diversity among patients, and recent research has shown the association of sex and gender with health. A growing body of literature describes widespread associations of sex and gender with cells, organs, and the manner in which individual patients interact with health care systems. Sex- and gender-informed medicine is a young paradigm of clinical practice and medical research founded on this literature that considers the association of sex and gender with each element of the disease process from risk, to presentation, to response to therapy.

OBSERVATIONS

Characteristics that underlie sex and gender involve both endogenous and exogenous factors that change throughout the life course. This review details clinical examples with broad applicability that highlight sex and gender differences in the key domains of genetics, epigenomic modifiers, hormonal milieu, immune function, neurocognitive aging process, vascular health, response to therapeutics, and interaction with health care systems. These domains interact with one another in multidimensional associations, contributing to the diversity of the sex and gender spectra. Novel research has identified differences of clinical relevance with the potential to improve care for all patients.

CONCLUSIONS AND RELEVANCE

Clinicians should consider incorporating sex and gender in their decision-making to practice precision medicine that integrates fundamental components of patient individuality. Recognizing the biological and environmental factors that affect the disease course is imperative to optimizing care for each patient. Research highlights the myriad ways sex and gender play a role in health and disease. However, these clinically relevant insights have yet to be systematically incorporated into care. The framework described in this review serves as a guide to help clinicians consider sex and gender as they practice precision medicine.

Cushing's syndrome: Consequences of late diagnosis after bariatric surgery

Prior to bariatric surgery, endocrine causes of obesity must be excluded. The diagnosis of osteoporosis in a male requires the study of secondary causes of this condition. The diagnostic delay of Cushing's syndrome may have irreversible consequences.

Role of irisin in androgen-deficient muscle wasting and osteopenia in mice

Androgen deficiency plays a crucial role in the pathogenesis of male osteoporosis and sarcopenia. Myokines have recently been identified as humoral factors that are involved in the interactions between muscle and bone; however, the influence of androgen deficiency on these interactions remains unclear. Therefore, we herein investigated the roles of humoral factors linking muscle to bone using orchidectomized mice with sarcopenia and osteopenia. Orchidectomy (ORX) significantly reduced muscle mass, grip strength, and trabecular bone mineral density (BMD) in mice. Among the myokines examined, ORX only significantly reduced fibronectin type III domain-containing 5 (Fndc5) mRNA levels in both the soleus and gastrocnemius muscles of mice. In simple regression analyses, Fndc5 mRNA levels in the soleus muscle positively correlated with trabecular BMD, but not cortical BMD. The administration of irisin, a product of Fndc5, significantly protected against the decrease induced in trabecular BMD, but not muscle mass, by androgen deficiency in mice. In conclusion, the present results demonstrated that androgen deficiency decreases the expression of irisin in the skeletal muscle of mice. Irisin may be involved in muscle/bone relationships negatively affected by androgen deficiency.

Changes in Bone Mineral Density in Women With Breast Cancer: A Prospective Cohort Study

BACKGROUND

Cancer treatment-induced bone loss is an important long-term effect among breast cancer survivors. Little is known, however, about the pattern of bone loss and the factors associated with it.

OBJECTIVE

The aim of this study was to examine annual bone health changes and factors associated with bone loss for 3 years after diagnosis among women with breast cancer.

METHODS

Ninety-nine newly diagnosed women with breast cancer (mean age, 51.1 years) were enrolled in a prospective longitudinal study. Bone mineral density (BMD) was measured with dual-energy x-ray absorptiometry at baseline and yearly for 3 years.

RESULTS

During the 3-year follow-up, the proportion of women who had osteopenia or osteoporosis increased from 33.3% to 62.5%. The BMD of the participants significantly decreased 6.8% in the lumbar spine, 4.6% in the femur neck, and 3.5% in the total hip, with bone loss the greatest in the first year. In multiple linear regression analysis, chemotherapy was significantly associated with bone loss at all sites, and premenopausal status at diagnosis was significantly related to bone loss at the lumbar spine. We found no significant relationship between health behavior status and BMD change at any site.

CONCLUSION

Women newly diagnosed with breast cancer can lose up to 6.8% of BMD during a 3-year follow-up. Chemotherapy and premenopausal status are important risk factors for bone loss.

IMPLICATIONS FOR PRACTICE

Identification of premenopausal women at diagnosis and monitoring BMD before and after chemotherapy are key for promoting bone health in women with breast cancer.

Bone Health and Bone-Targeted Therapies for Prostate Cancer: ASCO Endorsement of a Cancer Care Ontario Guideline

PURPOSE

In 2017, Cancer Care Ontario's Program in Evidence-Based Care released the Bone Health and Bone-Targeted Therapies for Prostate Cancer guideline. This guideline included recommendations across a relatively broad clinical spectrum within prostate cancer. Topics addressed ranged from management of osteoporotic fracture risk in nonmetastatic disease to management of men with castration-resistant prostate cancer metastatic to bone. ASCO has a policy and set of procedures for endorsing clinical practice guidelines that have been developed by other professional organizations.

METHODS

The Bone Health and Bone-Targeted Therapies for Prostate Cancer guideline was reviewed for developmental rigor by methodologists. An ASCO Expert Panel then reviewed the content and the recommendations.

RESULTS

The ASCO Expert Panel determined that the recommendations from the Bone Health and Bone-Targeted Therapies for Prostate Cancer guideline were clear, thorough, and based on the most relevant scientific evidence. ASCO wholly endorses the Bone Health and Bone-Targeted Therapies for Prostate Cancer guideline.

RECOMMENDATIONS

The ASCO Expert Panel endorses all the original guideline recommendations as written and offers a series of discussion points to guide practice for clinicians as they manage bone-related risks within this patient population.

Osteoporosis and fragility fractures: risk assessment, management and prevention

Osteoporosis is a chronic skeletal condition characterised by low bone mass and microarchitectural deterioration of the bones that disproportionately affects older people. Older people with osteoporosis are at increased risk of sustaining fragility fractures, and this risk is compounded by factors such as falls and frailty. Fragility fractures can have several physical and psychological effects, potentially affecting an older person's quality of life and reducing their life expectancy. Therefore, it is important that nurses can identify individuals at risk of osteoporosis and recognise the factors that may predict fragility fractures. This article outlines the main risk factors for osteoporosis and details the assessment and management of patients with this condition. It also explains the pharmacological interventions and lifestyle changes that can reduce the risk of fragility fractures in older people with osteoporosis.

Young cancer survivors have lower bone mineral density compared with healthy controls: a nationwide population-based study in Korea

Direct effects of cancer cells and various cancer treatments can cause bone loss in cancer survivors. The aim of this study was to assess the risk of bone loss in Korean cancer survivors, and the relationship between body composition and bone mineral density (BMD). We hypothesized that cancer survivors would have lower BMD than healthy people, and increased muscle mass has a protective effect on BMD. We measured BMD and body composition in 259 cancer survivors (99 men and 160 women). Subjects were selected from the Korean National Health and Nutrition Survey conducted from 2008 to 2011. Body composition and BMD were measured by dual-energy X-ray absorptiometry. We examined the linear trend of lumbar BMD according to tertiles of lean mass (LM) and fat mass (FM) by linear regression, adjusting for age, alcohol consumption, smoking, exercise, 25-hydroxyvitamin D, height, protein intake, and menopausal status. Cancer survivors under 50 years of age had lower lumbar BMD compared with healthy controls (0.93 ± 0.04 g/cm² vs. 1.02 ± 0.01 g/cm², p = 0.032 in males; 0.95 ± 0.02 g/cm² vs. 0.98 ± 0.01 g/cm², p = 0.015 in females). Lumbar BMD significantly increased from the lowest to highest tertiles of LM in male (p for trend < 0.001) and marginally significantly increased in female survivors (p for trend = 0.060). In this study of Korean cancer survivors, young survivors were at higher risk of having low lumbar BMD. Higher LM had beneficial effects on BMD in cancer survivors. To prevent osteoporosis and fractures, efforts to increase lean body mass, including bone, are needed for young cancer survivors.

Determinants of Bone Health Status in a Multi-Ethnic Population in Klang Valley, Malaysia

Background and objectives: Studies on osteoporosis risk factors are limited in Malaysia, so this study assesses the factors associated with bone health assessed using dual-energy X-ray absorptiometry (DXA) among Malaysians aged ≥40 years. Subjects and Methods: Data on demography, medical history, dietary and lifestyle practices of 786 Malaysians (51.4% women) aged ≥40 years recruited in Klang Valley were obtained. Their body composition and bone health were determined using DXA. The association between risk factors and bone health status was assessed using binary logistic regression. Results: The prevalence of suboptimal bone health and osteoporosis was higher in women (59.4% and 16.1%) than men (40.8% and 8.4%). Overall, the predictors of suboptimal bone health and osteoporosis among the subjects were increased age and higher fat mass. Lower monthly income was positively associated with osteoporosis. Being menopausal was a risk factor for both suboptimal bone health and osteoporosis in women. Women with no formal education were more likely to get osteoporosis. Being a smoker and Chinese were positively related to suboptimal bone health among men. Meanwhile, predictors of osteoporosis among men were regular alcohol and dairy product consumption, higher fat mass and having a tertiary education. Conclusions: This study calls for immediate and effective interventions for middle-aged and elderly populations with risk factors to halt the progression of bone loss.

Updated approach for the management of osteoporosis in Turkey: a consensus report

As a result of the current demographics, increased projections of osteoporosis (OP) and prevalence of the disease in Turkey, a panel of multidisciplinary experts developed a thorough review to assist clinicians in identifying OP and associated fracture risk patients, diagnosing the disease with the appropriate available diagnostic methods, classifying the disease, and initiating appropriate treatment. The panel expects to increase the awareness of this prevalent disease, decrease consequences of OP with corresponding cost savings and, ultimately, decrease the overall burden of OP and related fractures in Turkey.

BACKGROUND

OP is not officially accepted as a chronic disease in Turkey despite the high prevalence and predicted increase in the following years. However, there are areas where the country is performing well, such as having a country-specific fracture risk assessment model, DXA access, and the uptake of FRAX. Additional efforts are required to decrease the existing treatment gap estimating 75-90% of patients do not receive pharmacological intervention for secondary prevention, and the diagnosis rate is around 25%.

METHODS

A selected panel of Turkish experts in fields related to osteoporosis was provided with a series of relevant questions to address prior to the multi-day conference. Within this conference, each narrative was discussed and edited by the entire group, through numerous drafts and rounds of discussion until a consensus was achieved. Represented in the panel were a number of societies including The Turkish Osteoporosis Society, The Society of Endocrinology and Metabolism of Turkey (SEMT), and The Turkish Society of Physical Medicine and Rehabilitation.

RESULTS

Standardized general guidelines to identify OP and related fractures and at-risk population in Turkey, which will enable clinicians to accurately and effectively diagnose the disease, treat the appropriate patients with available pharmacological and non-pharmacological treatments and decrease the burden of the disease.

CONCLUSIONS

This manuscript provides a review of the current state of OP and related fractures in Turkey. Moreover, this manuscript reviews current international guidelines and national studies and proposes a number of helpful country-specific classifications that can be used by healthcare providers caring for the at-risk population. Additionally, the panel proposes practical recommendations that should be implemented nationally in order to decrease the burden of OP and related fractures and effectively preventing the burden in future generations.

Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition

Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk of future fracture. Patients need education, however, about the benefits and risks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive but may be beneficial for selected patients at high risk. Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the early post-fracture period, prompt treatment is recommended. Adequate dietary or supplemental vitamin D and calcium intake should be assured. Individuals being treated for osteoporosis should be reevaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring for adverse treatment effects. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease). © 2019 American Society for Bone and Mineral Research.

Estimation and projection about the standardized prevalence of osteoporosis in mainland China

We performed a systematic analysis of the standardized prevalence of osteoporosis in mainland China from 1990 to 2050.

INTRODUCTION

Osteoporosis is the most common bone disease. We aimed to investigate the standardized prevalence of osteoporosis in mainland China at the national and regional levels, with projections until 2050.

METHODS

A comprehensive literature search was performed in PubMed, EMBASE, Cochrane Library, CNKI, Wanfang, and CBM-SinoMed. We constructed resample sets to calculate the standardized prevalence in each study. Multilevel mixed-effects logistic regression was used to estimate the age-specific and sex-specific prevalence. The United Nations Population Division (UNPD) data and regional population data from the fifth and sixth censuses in mainland China were used to estimate and project the national and regional prevalence of osteoporosis.

RESULTS

The standardized prevalence of osteoporosis ranged from 5.04% (2.12~11.34%) to 7.46% (3.13~16.32%) in males aged ≥ 50 years and from 26.28% (15.38~40.40%) to 39.19% (25.74~53.95%) in females aged ≥ 50 years from 1990 to 2050. Moreover, we did not find a significant difference in the standardized prevalence among three geographic regions (Central China, West China, and East China).

CONCLUSION

We found that osteoporosis is a serious public health challenge in mainland China. The findings in our study add insight into the epidemiology of osteoporosis and would be beneficial for the prevention and treatment of osteoporosis in mainland China.

Pharmacotherapeutic Management Strategies for Thyroid Disease-Induced Pericarditis

Objective: To describe the various pharmacotherapeutic strategies in managing thyroid disease-induced pericarditis (TDIP). Considerations for both hypothyroid-induced and hyperthyroid-induced pericarditis will be discussed. Data Sources: A literature search of MEDLINE, including PubMed, was performed inclusive of all years, using the following search terms: thyroid disease, pericardial diseases, pericarditis, acute pericarditis, cholesterol pericarditis, hypothyroidism, hyperthyroidism, colchicine, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, methimazole, propylthiouracil, and P-glycoprotein. Product monographs were reviewed as well. Study Selection and Data Extraction: Relevant English-language studies and data as well as the most current guidelines for diagnosis and management of thyroid and pericardial diseases were considered. Because of limited data regarding the subject matter, no date range limits were established during literature search. Data Synthesis: It is well documented that thyroid dysfunction can adversely affect cardiovascular function. Additionally, there are published guidelines on the diagnosis and management of pericarditis and, separately, thyroid disease. There are limited data, however, on managing TDIP. The sequela of untreated TDIP can be detrimental. Relevance to Patient Care and Clinical Practice: Strategies on managing TDIP are scarcely reported in the literature. This review provides clinicians with a single reference source for treatment strategies toward managing hypothyroidism-induced and hyperthyroidism-induced pericarditis as well as significant drug interactions that can potentially confound the management of hypothyroidism- and hyperthyroidism-induced pericarditis. Conclusions: Treatment of TDIP involves addressing both the thyroid disease as well as the pericarditis. Along with treatment strategies, clinicians should also consider potential drug-drug and drug-disease interactions that can potentially worsen clinical outcomes.

Diagnosis and Treatment of Osteoporosis: What Orthopaedic Surgeons Need to Know

Osteoporosis, often called a silent disease, is a systemic condition of bone as a result of loss of bone mass and deterioration of its microarchitecture. The result is weakened bone, leading to an increased risk of fragility fractures. An estimated 9 million osteoporotic fractures occur every year worldwide. However, the true incidence of osteoporotic fractures is unknown because many are undetected. Astoundingly, this epidemic equates to an osteoporotic fracture every 3 seconds. Orthopaedic surgeons need to not only treat these fractures but also understand the underlying pathogenesis and risk factors to help prevent them. The management of osteoporosis is a critical part of musculoskeletal care. We must be familiar with the tools to assess osteoporosis and the treatments available, including risks and benefits. This review article is intended to deliver a review of the vast literature and provide the orthopaedic surgeon with the essential information necessary to manage the current osteoporosis epidemic.

Osteoporosis from an Endocrine Perspective: The Role of Hormonal Changes in the Elderly

Introduction: Osteoporosis is increasingly prevalent in the elderly, with fractures mostly occurring in women and men who are older than 55 and 65 years of age, respectively. The aim of this review was to examine the evidence regarding the influence of hormones on bone metabolism, followed by clinical data of hormonal changes in the elderly, in the attempt to provide possible poorly explored diagnostic and therapeutic candidate targets for the management of primary osteoporosis in the aging population. Material and methods: An extensive Medline search using PubMed, Embase, and Cochrane Library was performed. Results: While the rise in Thyroid-stimulating hormone (TSH) levels has a protective role on bone mass, the decline of estrogen, testosterone, Insulin-like growth factor 1 (IGF1), and vitamin D and the rise of cortisol, parathyroid hormone, and follicle-stimulating hormone (FSH) favor bone loss in the elderly. Particularly, the AA rs6166 FSH receptor (FSHR) genotype, encoding for a more sensitive FSHR than that encoded by the GG one, is associated with low total body mass density (BMD), independently of circulating estrogen. A polyclonal antibody with a FSHR-binding sequence against the β-subunit of murine FSH seems to be effective in ameliorating bone loss in ovariectomized mice. Conclusions: A complete hormonal assessment should be completed for both women and men during bone loss evaluation. Novel possible diagnostic and therapeutic tools might be developed for the management of male and female osteoporosis.

Screening to prevent fragility fractures among adults 40 years and older in primary care: protocol for a systematic review

PURPOSE

To inform recommendations by the Canadian Task Force on Preventive Health Care by systematically reviewing direct evidence on the effectiveness and acceptability of screening adults 40 years and older in primary care to reduce fragility fractures and related mortality and morbidity, and indirect evidence on the accuracy of fracture risk prediction tools. Evidence on the benefits and harms of pharmacological treatment will be reviewed, if needed to meaningfully influence the Task Force's decision-making.

METHODS

A modified update of an existing systematic review will evaluate screening effectiveness, the accuracy of screening tools, and treatment benefits. For treatment harms, we will integrate studies from existing systematic reviews. A de novo review on acceptability will be conducted. Peer-reviewed searches (Medline, Embase, Cochrane Library, PsycINFO [acceptability only]), grey literature, and hand searches of reviews and included studies will update the literature. Based on pre-specified criteria, we will screen studies for inclusion following a liberal-accelerated approach. Final inclusion will be based on consensus. Data extraction for study results will be performed independently by two reviewers while other data will be verified by a second reviewer; there may be some reliance on extracted data from the existing reviews. The risk of bias assessments reported in the existing reviews will be verified and for new studies will be performed independently. When appropriate, results will be pooled using either pairwise random effects meta-analysis (screening and treatment) or restricted maximum likelihood estimation with Hartun-Knapp-Sidnick-Jonkman correction (risk prediction model calibration). Subgroups of interest to explain heterogeneity are age, sex, and menopausal status. Two independent reviewers will rate the certainty of evidence using the GRADE approach, with consensus reached for each outcome rated as critical or important by the Task Force.

DISCUSSION

Since the publication of other guidance in Canada, new trials have been published that are likely to improve understanding of screening in primary care settings to prevent fragility fractures. A systematic review is required to inform updated recommendations that align with the current evidence base.

Bone health in diabetes and prediabetes

Bone fragility has been recognized as a complication of diabetes, both type 1 diabetes (T1D) and type 2 diabetes (T2D), whereas the relationship between prediabetes and fracture risk is less clear. Fractures can deeply impact a diabetic patient’s quality of life. However, the mechanisms underlying bone fragility in diabetes are complex and have not been fully elucidated. Patients with T1D generally exhibit low bone mineral density (BMD), although the relatively small reduction in BMD does not entirely explain the increase in fracture risk. On the contrary, patients with T2D or prediabetes have normal or even higher BMD as compared with healthy subjects. These observations suggest that factors other than bone mass may influence fracture risk. Some of these factors have been identified, including disease duration, poor glycemic control, presence of diabetes complications, and certain antidiabetic drugs. Nevertheless, currently available tools for the prediction of risk inadequately capture diabetic patients at increased risk of fracture. Aim of this review is to provide a comprehensive overview of bone health and the mechanisms responsible for increased susceptibility to fracture across the spectrum of glycemic status, spanning from insulin resistance to overt forms of diabetes. The management of bone fragility in diabetic patient is also discussed.

Protective Effects of Melon Extracts on Bone Strength, Mineralization, and Metabolism in Rats with Ovariectomy-Induced Osteoporosis

A polyphenolic extract from melon (Cucumis melo L.), as a potential source of natural antioxidants, has been reported to have a positive effect on osteoblast activity. In this study, the protective effects of heat-treated melon extract (ECO-A) on bone strength, mineralization, and metabolism were examined in osteoporotic rat models. Osteoporosis was induced by ovariectomy (OVX) in female rats and then maintained for 8 weeks, along with the ingestion of phosphate-buffered saline (PBS, OVXP) or ECO-A (OVXE) for an additional 4 weeks. At a pre-determined timepoint, bone strengths, as well as bone mineral contents (BMC) and the density (BMD) of femurs and/or lumbar spines extracted from each animal, were measured by a mechanical test and dual-energy X-ray absorptiometry, respectively. Moreover, several biochemical markers for bone turnover were analyzed by respective colorimetric assay kits in addition to clinical analyses. The maximum load and stiffness of femurs from the OVXE group were found to be significantly higher than the other groups. Furthermore, the OVXE group showed significantly higher BMC, BMD, and bone volume than the OVX and OVXP groups, which were comparable to the non-OVX (sham) group. The levels of bone formation and resorption markers in the OVXE group were similar to the sham group, but significantly different from other groups. In conclusion, these results suggest that ECO-A can play potentially positive roles in the protection of bone loss in rats with OVX-induced osteoporosis.

Does Routine Anti-Osteoporosis Medication Lower the Risk of Fractures in Male Subjects? An Updated Systematic Review With Meta-Analysis of Clinical Trials

Background: Several epidemiological articles have reported the correlations between anti-osteoporosis medication and the risks of fractures in male and female subjects, but the specific efficacy of anti-osteoporosis medication for male subjects remains largely unexplored. Objective: The aim of this study was to evaluate the correlation between anti-osteoporosis medication and the risk of fracture in relation to low bone mass [including outcomes of osteoporosis, fracture, and bone mineral density (BMD) loss] in male subjects analyzed in studies within the updated literature. Methods: Randomized controlled trials (RCTs) that analyzed the effectiveness of a treating prescription for male subjects with osteoporosis (or low BMD) and that focused on the outcomes of fracture were included. Relevant studies from Embase, Web of Science, PubMed, and Chinese database of CNKI were retrieved from inception to January 30th, 2019. Two staff members carried out the eligibility assessment and data extraction. The discrepancies were settled by consultation with another researcher. We calculated the pooled relative risks (RRs) based on 95% confidence intervals (CIs). Results: Twenty-seven documents (28 studies) with 5,678 subjects were identified. For the category of bisphosphonates, significant results were observed in pooled analyses for decreased risk of the vertebral fracture domain (RR, 0.44 [95% CI, 0.31-0.62]), nonvertebral fracture domain (RR, 0.63 [95% CI, 0.46-0.87]), and clinical fracture domain (RR, 0.59 [95% CI, 0.48-0.72]) compared with those of controls. Participants with bisphosphonates had a 56% (95% CI = 38-69%) lower risk of vertebral fractures, 37% (95% CI = 13-54%) lower risk of nonvertebral fractures, and 41% (95% CI = 28-52%) lower risk of clinical fractures. Furthermore, meta-analyses also demonstrated a decreased risk of the vertebral fracture domain via treatment with risedronate (RR, 0.45 [95% CI, 0.28-0.72]) and alendronate (RR, 0.41 [95% CI, 0.23-0.74]), but not with calcitriol, calcitonin, denosumab, ibandronate, monofluorophosphate, strontium ranelate, teriparatide, or zoledronic acid, compared with that of controls. Conclusions: This systematic review confirms that bisphosphonates were connected with a decreased risk of vertebral fractures, nonvertebral fractures, and clinical fractures for male subjects with osteoporosis. Future research is needed to further elucidate the role of nonbisphosphonates in treating fractures of osteoporosis subjects.

Testing and management for monoclonal gammopathy of uncertain significance and myeloma patients presenting with osteoporosis and fragility fractures

Multiple myeloma, the second most frequent blood cancer, and its precursor, monoclonal gammopathy of uncertain significance, are associated with an increased risk of fragility fractures. However, current guidelines fail to offer explicit indications for healthcare professionals in terms of testing and thresholds for onward referral. The purpose of this review is to present the association of these conditions and metabolic bone disease and to highlight the importance of considering a diagnosis of monoclonal gammopathy of uncertain significance and myeloma in the context of a secondary fracture prevention assessment and of a multidisciplinary approach in managing these patients.