Non-pharmacological management of osteoporosis: a consensus of the Belgian Bone Club

The role of lipid metabolism in osteoporosis: Clinical implication and cellular mechanism

In recent years, researchers have become focused on the relationship between lipids and bone metabolism balance. Moreover, many diseases related to lipid metabolism disorders, such as nonalcoholic fatty liver disease, atherosclerosis, obesity, and menopause, are associated with osteoporotic phenotypes. It has been clinically observed in humans that these lipid metabolism disorders promote changes in osteoporosis-related indicators bone mineral density and bone mass. Furthermore, similar osteoporotic phenotype changes were observed in high-fat and high-cholesterol-induced animal models. Abnormal lipid metabolism (such as increased oxidized lipids and elevated plasma cholesterol) affects bone microenvironment homeostasis via cross-organ communication, promoting differentiation of mesenchymal stem cells to adipocytes, and inhibiting commitment towards osteoblasts. Moreover, disturbances in lipid metabolism affect the bone metabolism balance by promoting the secretion of cytokines such as receptor activator of nuclear factor-kappa B ligand by osteoblasts and stimulating the differentiation of osteoclasts. Conclusively, this review addresses the possible link between lipid metabolism disorders and osteoporosis and elucidates the potential modulatory mechanisms and signaling pathways by which lipid metabolism affects bone metabolism balance. We also summarize the possible approaches and prospects of intervening lipid metabolism for osteoporosis treatment.

Prevalence and differences in the co-administration of drugs known to interact: an analysis of three distinct and large populations

BACKGROUND

The co-administration of drugs known to interact greatly impacts morbidity, mortality, and health economics. This study aims to examine the drug-drug interaction (DDI) phenomenon with a large-scale longitudinal analysis of age and gender differences found in drug administration data from three distinct healthcare systems.

METHODS

This study analyzes drug administrations from population-wide electronic health records in Blumenau (Brazil; 133 K individuals), Catalonia (Spain; 5.5 M individuals), and Indianapolis (USA; 264 K individuals). The stratified prevalences of DDI for multiple severity levels per patient gender and age at the time of administration are computed, and null models are used to estimate the expected impact of polypharmacy on DDI prevalence. Finally, to study actionable strategies to reduce DDI prevalence, alternative polypharmacy regimens using drugs with fewer known interactions are simulated.

RESULTS

A large prevalence of co-administration of drugs known to interact is found in all populations, affecting 12.51%, 12.12%, and 10.06% of individuals in Blumenau, Indianapolis, and Catalonia, respectively. Despite very different healthcare systems and drug availability, the increasing prevalence of DDI as patients age is very similar across all three populations and is not explained solely by higher co-administration rates in the elderly. In general, the prevalence of DDI is significantly higher in women - with the exception of men over 50 years old in Indianapolis. Finally, we show that using proton pump inhibitor alternatives to omeprazole (the drug involved in more co-administrations in Catalonia and Blumenau), the proportion of patients that are administered known DDI can be reduced by up to 21% in both Blumenau and Catalonia and 2% in Indianapolis.

CONCLUSIONS

DDI administration has a high incidence in society, regardless of geographic, population, and healthcare management differences. Although DDI prevalence increases with age, our analysis points to a complex phenomenon that is much more prevalent than expected, suggesting comorbidities as key drivers of the increase. Furthermore, the gender differences observed in most age groups across populations are concerning in regard to gender equity in healthcare. Finally, our study exemplifies how electronic health records' analysis can lead to actionable interventions that significantly reduce the administration of known DDI and its associated human and economic costs.

Isoflavone intervention and its impact on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials

Due to estrogen deficiency, postmenopausal women may suffer from an imbalance in bone metabolism that leads to bone fractures. Isoflavones, a type of phytoestrogen, have been suggested to improve bone metabolism and increase bone mass. Therefore, isoflavones are increasingly recognized as a promising natural alternative to hormone replacement therapy for postmenopausal women who face a heightened risk of osteoporosis and are susceptible to bone fractures.

PURPOSE

This study aimed to evaluate the efficacy of isoflavone interventions on bone mineral density (BMD) in postmenopausal women by means of systematic review and meta-analysis.

METHODS

The electronic database searches were performed on PubMed, Embase, Scopus, and Cochrane Library databases, covering literature up to April 20, 2023. A random-effects model was used to obtain the main effect estimates, with a mean difference (MD) and its 95% confidence interval (CI) as the effect size summary. The risk of bias assessment was conducted using the Risk of Bias 2 (RoB2) tool.

RESULTS

A total of 63 randomized controlled trials comparing isoflavone interventions (n = 4,754) and placebo (n = 4,272) were included. The results indicated that isoflavone interventions significantly improved BMD at the lumbar spine (MD = 0.0175 g/cm2; 95% CI, 0.0088 to 0.0263, P < 0.0001), femoral neck (MD = 0.0172 g/cm2; 95% CI, 0.0046 to 0.0298, P = 0.0073), and distal radius (MD = 0.0138 g/cm2; 95% CI, 0.0077 to 0.0198, P < 0.0001) in postmenopausal women. Subgroup analysis showed that the isoflavone intervention was effective for improving BMD when the duration was ≥ 12 months and when the intervention contained genistein of at least 50 mg/day.

CONCLUSION

This systematic review and meta-analysis suggests that isoflavone interventions, especially those containing genistein of at least 50 mg/day, can effectively enhance BMD in postmenopausal women.

Dietary iron intake and its impact on osteopenia/osteoporosis

BACKGROUND

Osteoporosis is a prevalent condition characterized by low bone density and increased risk of fractures, resulting in a significant healthcare burden. Previous research has suggested that serum ferritin levels may be related to the risk of developing osteoporosis. The aim of this study was to investigate the relationship between dietary iron intake and the development of osteoporosis.

METHODS

Using data from the National Health and Nutrition Examination Survey (NHANES) conducted between 2005 and 2018, a total of 11,690 adults aged over 20 were evaluated. Bone mineral density (BMD) measurements of the femoral neck and lumbar spine were used to assess osteoporosis and osteopenia. Dietary iron intake was determined using food intake interviews and the Food and Nutrient Database for Dietary Studies. Logistic regression models were applied to investigate the association between dietary iron consumption and osteopenia and osteoporosis.

RESULTS

After adjusting for sociodemographic factors, compared with those who had the first quartile (Q1) of dietary iron intake, the odds ratio (OR) for osteopenia across the quartiles of dietary iron intake levels was 0.88 (95%CI: 0.79-0.98), 0.80 (95%CI: 0.72-0.89), and 0.74 (95%CI: 0.67-0.83) for Q2, Q3, and Q4, respectively. And the OR for osteoporosis across the quartiles of dietary iron intake levels was 1.00, 0.77 (95%CI: 0.50-1.19), 0.54 (95%CI: 0.34-0.89), and 0.83 (95%CI: 0.54-1.29) for Q1, Q2, Q3, and Q4, respectively. Notably, the observed association was significant among females but not males.

CONCLUSION

The risk of osteopenia/osteoporosis in females decreases with a moderate increase in dietary iron consumption. For females to preserve bone health, moderately increasing their dietary iron intake without overindulging should be seen as a key approach. Our study provides useful insights for developing dietary strategies to prevent and manage osteoporosis in vulnerable populations.

Analysis of electronic health records from three distinct and large populations reveals high prevalence and biases in the co-administration of drugs known to interact

The co-administration of drugs known to interact has a high impact on morbidity, mortality, and health economics. We study the drug-drug interaction (DDI) phenomenon by analyzing drug administrations from population-wide Electronic Health Records (EHR) in Blumenau (Brazil), Catalonia (Spain), and Indianapolis (USA). Despite very different health care systems and drug availability, we find a common large risk of DDI administration that affected 13 to 20% of patients in these populations. In addition, the increasing risk of DDI as patients age is very similar across all three populations but is not explained solely by higher co-administration rates in the elderly. We also find that women are at higher risk of DDI overall- except for men over 50 years old in Indianapolis. Finally, we show that PPI alternatives to Omeprazole can reduce the number of patients affected by known DDIs by up to 21% in both Blumenau and Catalonia, and 2% in Indianapolis, exemplifying how analysis of EHR data can lead to a significant reduction of DDI and its associated human and economic costs. Although the risk of DDIs increases with age, administration patterns point to a complex phenomenon that cannot be solely explained by polypharmacy and multimorbidity. The lack of safer drug alternatives, particularly for chronic conditions, further overburdens health systems, thus highlighting the need for disruptive drug research.

The efficacy of femoral augmentation for hip fracture prevention using ceramic-based cements: A preliminary experimentally-driven finite element investigation

Femoral fractures due to sideways falls continue to be a major cause of concern for the elderly. Existing approaches for the prevention of these injuries have limited efficacy. Prophylactic femoral augmentation systems, particularly those involving the injection of ceramic-based bone cements, are gaining more attention as a potential alternative preventative approach. We evaluated the mechanical effectiveness of three variations of a bone cement injection pattern (basic ellipsoid, hollow ellipsoid, small ellipsoid) utilizing finite element simulations of sideways fall impacts. The basic augmentation pattern was tested with both high- and low-strength ceramic-based cements. The cement patterns were added to the finite element models (FEMs) of five cadaveric femurs, which were then subject to simulated sideways falls at seven impact velocities ranging from 1.0 m/s to 4.0 m/s. Peak impact forces and peak acetabular forces were examined, and failure was evaluated using a strain-based criterion. We found that the basic HA ellipsoid provided the highest increases in both the force at the acetabulum of the impacted femur ("acetabular force", 55.0% ± 22.0%) and at the force plate ("impact force", 37.4% ± 15.8%). Changing the cement to a weaker material, brushite, resulted in reduced strengthening of the femur (45.2% ± 19.4% acetabular and 30.4% ± 13.0% impact). Using a hollow version of the ellipsoid appeared to have no effect on the fracture outcome and only a minor effect on the other metrics (54.1% ± 22.3% acetabular force increase and 35.3% ± 16.0% impact force increase). However, when the outer two layers of the ellipsoid were removed (small ellipsoid), the force increases that were achieved were only 9.8% ± 5.5% acetabular force and 8.2% ± 4.1% impact force. These results demonstrate the importance of supporting the femoral neck cortex to prevent femoral fractures in a sideways fall, and provide plausible options for prophylactic femoral augmentation. As this is a preliminary study, the surgical technique, the possible effects of trabecular bone damage during the augmentation process, and the effect on the blood supply to the femoral head must be assessed further.

Physiological and Ankle Functions Are Discriminating Factors for the Risk of Falls in Women in Treatment of Osteoporosis

INTRODUCTION

Elderly women with osteoporosis are at risk of falls and fractures.

OBJECTIVE

To compare the intrinsic factors of falls, including ankle evaluation, in a group of elderly women in treatment for osteoporosis compared with a control group.

METHODS

A cross-sectional study of elderly women in treatment for osteoporosis (TG) was paired with a control group (CG) not in treatment. All groups completed a questionnaire and underwent a bone mineral density test; the mini-mental state examination (MMSE); physical performance tests; lower-limb strength and power, ankle, and muscle architecture evaluations; and a physiological profile assessment (PPA).

RESULTS

A total of 128 women were included (68 TG, 60 CG); the mean age was 71.55 ± 3.07 years; TG had a worse performance in the intrinsic factors in the MMSE, plantarflexions range of motion, gait speed, plantarflexions peak isometric strength, and short physical performance battery (p < 0.05 for all). PPA stratification (proprioception and lower-limb strength) presented a greater risk of falls in the TG, with proprioception increasing the risk by 2.4 times.

CONCLUSION

Patients undergoing treatment for osteoporosis are influenced by intrinsic factors of falls, many being present in the CG. PPA and ankle strength and flexibility tests are more discriminative for evaluating fall risks in patients in treatment for osteoporosis.

Similarities and Differences in Bone Mineral Density between Multiple Sites in the Same Individual: An Elderly Cadaveric Study

Bone mineral density (BMD) is known to vary based on various factors, and the degree of variation is site-specific. However, few studies have investigated the relationship between bone density at trabecular bone-rich and cortical bone-rich sites in the same individual. In this study, we attempted to measure BMD at multiple sites using whole-body computed tomography images taken immediately after death and to clarify the similarities and differences between skeletal sites. Additionally, we aimed to examine the factors that influence changes in BMD, such as the loading environment, bone microstructure, and the ossification process of each skeletal region. A 3D model containing BMD data of the skull, clavicle, lumbar vertebrae, and femur (neck and diaphysis) was created using computed tomography images taken immediately after the death of 60 individuals (28 men and 32 women, average age: 84.0 years) who consented to participate in the study before death. Arbitrary measurement sites were defined, and bone density was measured at each site. We found that the BMDs of all regions were negatively correlated with age, but this correlation was weaker in the skull than in other regions. The negative correlation was especially pronounced in areas with more trabecular bones in men and in areas with more cortical bones in women. Furthermore, these findings suggest that factors, such as the loading environment, bone microstructure, and the ossification process of the skeletal sites, affect the BMD. Furthermore, our results suggest that it is important to assess the BMD of cortical bone in older women.

Patient preferences for lifestyle behaviours in osteoporotic fracture prevention: a cross-European discrete choice experiment

Using a discrete choice experiment, we aimed to assess patients' preferences with regard to adopting lifestyle behaviours to prevent osteoporotic fractures. Overall, the 1042 patients recruited from seven European countries were favourable to some lifestyle behaviours (i.e., engaging in moderate physical activity, taking calcium and vitamin D supplements, reducing their alcohol consumption and ensuring a normal body weight).

INTRODUCTION

Alongside medical therapy, healthy lifestyle habits are recommended for preventing osteoporotic fractures. In this study, we aimed to assess patients' preferences with regard to adopting lifestyle changes to prevent osteoporotic fractures.

METHODS

A discrete choice experiment was conducted in seven European countries. Patients with or at risk of osteoporosis were asked to indicate to what extent they would be motivated to adhere to 16 lifestyle packages that differed in various levels of 6 attributes. The attributes and levels proposed were physical activity (levels: not included, moderate or high), calcium and vitamin D status (levels: not included, taking supplements, improving nutrition and assuring a minimal exposure to sunlight daily), smoking (levels: not included, quit smoking), alcohol (levels: not included, moderate consumption), weight reduction (levels: not included, ensure a healthy body weight) and fall prevention (levels: not included, receiving general advice or following a 1-day fall prevention program). A conditional logit model was used to estimate a patient's relative preferences for the various attributes across all participants and per country.

RESULTS

In total, 1042 patients completed the questionnaire. Overall, patients were favourable to lifestyle behaviours for preventing osteoporotic fractures. However, among the lifestyle behaviours proposed, patients were consensually not prone to engage in a high level of physical activity. In addition, in Ireland, Belgium, the Netherlands and Switzerland, patients were also not inclined to participate in a 1-day fall prevention program and Belgian, Swiss and Dutch patients were not prone to adhere to a well-balanced nutritional program. Nevertheless, we observed globally that patients felt positively about reducing their alcohol consumption, engaging in moderate physical activity, taking calcium and vitamin D supplements and ensuring a normal body weight, all measures aimed at preventing fractures.

CONCLUSIONS

In a patient-centred approach, fracture prevention should take these considerations and preferences into account.

The Effect of Yoga Asana "Vrksasana (Tree Pose)" on Balance in Patients With Postmenopausal Osteoporosis: A Randomized Controlled Trial

OBJECTIVE

In this study, the effect of the add-on effect of the Tree Pose (Vrksasana) on the balance of patients with postmenopausal osteoporosis was investigated.

DESIGN

Thirty-two patients with postmenopausal osteoporosis were randomly assigned to conservative exercise group (30 mins/d for 12 wks) or Tree Pose-added exercise group (30-min conventional exercise + 2-min Tree Pose/d for 12 wks) by Microsoft Excel randomization option. The balance of the patients was evaluated with Berg Balance Scale, Timed Up and Go Test, single-leg standing test, tandem walk test, tandem stance test, and Korebalance static&dynamic balance tests at baseline, sixth week, and third month of the exercise program.

RESULTS

There was no statistically significant difference on baseline data between groups. There was a statistically significant difference between the two groups in the sixth-week measurement of single-leg stance (P < 0.05). In the Berg Balance Scale, static balance test, dynamic balance test, and tandem walk test, a statistically significant difference was found among baseline, sixth-week, and 12th week measurements in both the exercise group and the Tree Pose-added exercise group.

CONCLUSIONS

Gains in the static and dynamic balance of postmenopausal osteoporotic patients can be obtained by adding "Vrksasana" to conventional exercises.

Are the physical activity habits of Turkish physiotherapists associated with their physical activity promotion and counseling?

Background: Physiotherapists (PTs) must be role models and convincing promoters of physical activity (PA). Objective: This cross-sectional study aimed to determine whether Turkish PTs' PA promotion and counseling practices are associated with their own PA habits. Method: An open-access survey was distributed to 2,619 PTs via e-mail to collect information about the PTs' PA habits; their knowledge, role perception, confidence, perceived barriers and feasibility in PA promotion; and their counseling practices. During the year that the survey was online, 421 (16.1%) PTs responded. The PTs were divided into two groups: physically active PTs (engaged in at least one type of PA) and inactive PTs. Chi-square test of independence was used for data analysis. Results: Knowledge of PA did not differ between the groups (p>0.05). Physically active PTs had higher role perception (except in one item) and greater confidence in PA promotion than inactive PTs (p<0.05). Except for one barrier, engagement in PA was not associated with perceived barriers or feasibility in PA promotion (p>0.05). Significantly more physically active PTs suggested PA to 10 or more patients/month [25.2% (n=40), vs. 13.5% (n=26); p=0.005] and suggested at least one type of PA [78.7% (n=137) vs. 59.2% (n=141); p=0.000]. PTs who engaged in vigorous-intensity PA and strength training were significantly more likely to suggest these types of PA than PTs who did not [44.1% (n=15) vs. 10.4% (20); p=0.000 and 91.1% (n=113) vs. 83.2% (n=154); p=0.047, respectively]. Conclusion: This study demonstrated that physically active PTs had higher role perception and confidence, and more actively promoted PA in their counseling practice.

How much do patients know about osteoporosis? A survey among patients referred to the dual-energy X-ray absorptiometry exam

BACKGROUND

Inadequate osteoporosis education can make patients ill-informed concerning preventive and therapeutic interventions and creates misconceptions and unnecessary concerns about the disease.

AIM

Our study aimed to assess whether patients referred to the DXA exam by their general practitioner are informed about risk factors for osteoporosis, comparing patients who received a diagnosis of osteoporosis before the exam with those without this diagnosis.

METHODS

An observational single-center study was performed among patients who were referred to the DXA exam at the Osteoporosis Service of Marche Nord Hospital (Fano, Italy) between April and July 2019. Socio-demographic and clinical characteristics, awareness of suffering from osteoporosis, femoral and lumbar spine T-score and bone mineral density, risk of fracture and the I-FOOQ score were assessed.

RESULTS

A pilot study was carried out to validate the questionnaire in the Italian language (alpha-Cronbach 0.75). After that, a sample of 128 patients was enrolled (response rate 93.3%). Mean age was 66 ± 10.6 years, 95.6% were women. Overall, I-FOOQ mean score was 12 ± 3.5. Age, educational level, menopausal age, body mass index, femoral T-score were not associated with a better knowledge (p > 0.05). A comparison between who know to suffer from osteoporosis and others found no differences (12.2 ± 3.4 and 12 ± 3.5, respectively, p = 0.772). Effect of walking, recommended calcium intake, and familiar predisposition are the less known topics.

CONCLUSION

Patients who undergo the DXA exam are poorly informed about risk factors for osteoporosis, independently of age, education, bone mineral density and risk of fracture. Knowing to suffer from osteoporosis does not increase the likelihood to be informed. It is mandatory to improve the education that is provided to the patients, as there are effective non-pharmacological interventions to prevent and treat osteoporosis.

Prophylactic augmentation implants in the proximal femur for hip fracture prevention: An in silico investigation of simulated sideways fall impacts

Femoral fractures from sideways falls in the elderly are associated with significant rates of morbidity and mortality. Approaches to prevent these catastrophic injuries include pharmacological treatments, which have limited efficacy. Prophylactic femoral augmentation systems are a promising alternative that are gaining prominence by addressing the most debilitating osteoporosis-related fracture. We have developed finite element models (FEMs) of a novel experimental sideways fall simulator for cadavers. By virtue of the range of specimens and injury outcomes, these FEMs are well-suited to the evaluation of such implants. The purpose of this study was to use the FEMs to evaluate the mechanical effectiveness of three different prophylactic femoral augmentation systems. Models of the Y-Strut® (Hyprevention®, Pessac, France), Gamma Nail® (Stryker, Kalamazoo, USA), and a simple lag screw femoral fracture implant systems were placed into FEMs of five cadaveric pelvis-femur constructs embedded in a soft tissue surrogate, which were then subject to simulated sideways falls at seven impact velocities. Femur-only FEMs were also evaluated. Peak impact forces and peak acetabular forces were examined, and failure was evaluated using a strain-based criterion. We found that the femoral augmentation systems increased the peak forces prior to fracture, but were unable to prevent fracture for severe impacts. The Gamma Nail® system consistently produced the largest strength increases relative to the unaugmented femur for all five specimens in both the pendulum-drop FEMs and the femur-only simulations. In some cases, the same implant appeared to cause fractures in the acetabulum. The femur-only FEMs showed larger force increases than the pendulum-drop simulations, which suggests that the results of the femur-only simulations may not represent sideways falls as accurately as the soft tissue-embedded pendulum-drop simulations. The results from this study demonstrate the ability to simulate a high energy phenomenon and the effect of implants in an in silico environment. The results also suggest that implants could increase the force applied to the proximal femur during impact. Fracture outcomes from the tested implants can be used to inform the design of future devices, which reaffirms the value of modelling with biofidelic considerations in the implant design process. To the authors' knowledge, this is the first paper to use more complex biofidelic FEMs to assess prophylactic femoral augmentation methods.

Identification of Rare LRP5 Variants in a Cohort of Males with Impaired Bone Mass

Osteoporosis is the most common bone disease characterized by reduced bone mass and increased bone fragility. Genetic contribution is one of the main causes of primary osteoporosis; therefore, both genders are affected by this skeletal disorder. Nonetheless, osteoporosis in men has received little attention, thus being underestimated and undertreated. The aim of this study was to identify novel genetic variants in a cohort of 128 males with idiopathic low bone mass using a next-generation sequencing (NGS) panel including genes whose mutations could result in reduced bone mineral density (BMD). Genetic analysis detected in eleven patients ten rare heterozygous variants within the LRP5 gene, which were categorized as VUS (variant of uncertain significance), likely pathogenic and benign variants according to American College of Medical Genetics and Genomics (ACMG) guidelines. Protein structural and Bayesian analysis performed on identified LRP5 variants pointed out p.R1036Q and p.R1135C as pathogenic, therefore suggesting the likely association of these two variants with the low bone mass phenotype. In conclusion, this study expands our understanding on the importance of a functional LRP5 protein in bone formation and highlights the necessity to sequence this gene in subjects with idiopathic low BMD.

Endurance running prevents the age-related decline of calcaneal bone stiffness

This investigation presents a comparison of calcaneus bone stiffness of endurance runners of different ages and age-matched controls. We found that there was an age-associated decline in calcaneus bone stiffness in the control group while endurance runners prevented this decline, with a higher effect as the participants increased their age.

PURPOSE

Previous investigations have found that endurance runners have higher bone mineral density and other bone quality variables in mechanically loaded bones. However, it is unknown if endurance running might counteract the decline in bone stiffness that occurs with age. The purpose of this study was to compare calcaneus bone stiffness of endurance runners of different ages to age-matched controls.

METHODS

In a descriptive cross-sectional study, 182 endurance-trained male runners and 116 healthy untrained male controls underwent an ultrasonographic assessment of the calcaneus bone in the right and left heels. Calcaneal bone stiffness was calculated from assessments of the broadband ultrasound attenuation and the speed of sound.

RESULTS

The line of best fit for the association between age and calcaneus stiffness was different between marathoners and controls (Z =  - 2.1, P = 0.02). A two-way ANCOVA (condition × age) with body mass, and body mass index as covariates, revealed that there were main effects of condition (F = 26.8, P < 0.01) and age (F = 4.2, P < 0.01) for calcaneus stiffness, with a significant interaction between these two factors (F = 2.8, P = 0.03). The post hoc analysis revealed that calcaneus stiffness was significantly higher in marathoners of 40-44 years (121.5 ± 18.2 vs 101.1 ± 21.3 arbitrary units [A.U.], P = 0.01), 45-49 years (121.5 ± 19.7 vs 104.3 ± 13.4 A.U., P = 0.04), and > 50 years (111.2 ± 17.9 vs 92.4 ± 16.0 A.U., P < 0.01) than their untrained counterparts of the same age with no statistically significant differences in the remaining age groups.

CONCLUSION

Endurance runners of > 40 years had higher values of calcaneus stiffness than controls, providing evidence to support the potential effect of endurance running to reduce the age-related decline on calcaneus bone stiffness.

Management of osteoporosis in older men

As many as one out of three fragility fractures occur in older men and the outcome of major osteoporotic fractures, in particular hip fractures, is worse in men than in women. Osteoporosis in older men is thus an important threat to the quality of life of individual patients and a considerable burden for society. However, only a small minority of older men with high or very high fracture risk are receiving therapy. This does not need to be so as tools for fracture risk assessment are available and several drugs have been approved for treatment. Nevertheless, the evidence base for the management of osteoporosis in older men remains limited. This narrative review summarises the evidence for older men on the burden of osteoporosis, the pathophysiology of fragility fractures, the clinical presentation, diagnosis and risk assessment, the patient evaluation, and the non-pharmacological and pharmacological management.

Effects of maximal strength training on bone mineral density in people living with HIV and receiving anti-retroviral therapy: a pilot study

BACKGROUND

Anti-retroviral therapy (ART) is associated with low bone mineral density (BMD) among people living with HIV (PLWHIV). Although physical activity is recommended for improving bone health in patients with reduced BMD, data on effects of strength exercises on low BMD among PLWHIV is scarce. This study therefore aimed to determine the effects of a 12 weeks maximal strength training (MST) on BMD among PLWHIV in Blantyre, Malawi.

METHODS

Twenty-six PLWHIV with reduced BMD were randomised into a training group (TG, n = 15) and control group (CG, n = 11). The TG underwent 12 weeks of MST consisting of 4 sets of 3 to 5 repetitions at 85-90% of one repetition maximum (1RM) 3 times per week. The CG was advised to maintain their usual lifestyle. Measurements of BMD using dual-energy X-ray absorptiometry, 1RM using a squat machine, heart rate using a heart rate monitor, weight, height and body mass index were obtained before and after the intervention in the TG and CG. Descriptive statistics and student's t - tests were used to analyse data.

RESULTS

The study was conducted for 12 weeks. Data of 24 participants [14 (TG) and 10 (CG)] were analysed. At base line, there were no significant differences in age (p = 0.34), height (p = 0.91), weight (p = 0.43) and body mass index (p = 0.34) between participants in the TG and the CG. After the intervention, there were significant improvements in lumbar BMD (p < 0.001) and resting heart rate (p = 0.03) in the TG compared to the CG. There were significant improvements in muscle strength (1 RM) in both the TG (p < 0.001) and the CG (p = 0.01).

CONCLUSIONS

MST improves lumbar BMD and strength in PLWHIV receiving ART in Blantyre, Malawi. MST with a shorter exercise duration of 12 weeks seem to have the potential in treating reduced BMD in PLWHIV.

TRIAL REGISTRATION

PACTR201712002889203. Registered with the Pan African Clinical Trial Registry on 22nd December, 2017 at www. pactr.org.

Prediction of 5-year mortality risk by malnutrition according to the GLIM format using seven pragmatic approaches to define the criterion of loss of muscle mass

OBJECTIVES

To assess the association between baseline malnutrition according to the GLIM format, using seven pragmatic approaches to define the criterion of loss of muscle mass, with mortality in the SarcoPhAge (Sarcopenia and Physical Impairment with advancing Age) study during a 5-year follow-up. Secondarily, to calculate diagnostic performance indicators, concordance, and feasibility of these 7 pragmatic approaches compared to the original GLIM criteria.

METHODS

Post-hoc analysis of the SarcoPhAge cohort, which included 534 community-dwelling volunteers ≥65-year-old, followed-up from 2013 to 2019. Baseline malnutrition was defined by GLIM criteria and 7 approaches: 1) Omission of a reduced muscle mass as a criterion; 2) Substitution for handgrip strength, 3) Calf-circumference, 4) Mid-arm circumference, 5) Goodman's grid, 6) Ishii's score chart, and 7) Yu's formula. The association between malnutrition (according to GLIM criteria and the 7 approaches) and mortality was assessed by Cox-regressions. Sensitivity, Specificity, Positive (PPV), Negative (NPV) predictive values, area under the curve (AUC), Cohen-kappa coefficient, and TELOS-feasibility score were calculated.

RESULTS

Data to calculate GLIM criteria were available for 373 subjects (73.07 ± 5.96 years, 56% women). Prevalence of malnutrition with GLIM criteria was 24.4% (ranged from 13.9% to 20.9% with the 7 approaches). GLIM criteria showed a HR = 3.38 (1.89-6.09) to predict mortality during the 5-year follow-up, which ranged from HR = 2.72 (1.51-4.91) to 3.94 (2.14-7.24) with the 7 approaches. All 7 approaches were feasible (TELOS ≥ 3), showed sensitivity ≥ 65%, specificity ≥ 95.4%, PPV ≥ 85%, NPV ≥ 88%, AUC ≥ 0.7 and had almost-perfect/strong concordance (k ≥ 0.7) with the original GLIM criteria.

CONCLUSIONS

GLIM criteria and the 7 approaches predicted three-to four-fold mortality, all ensured an accurate diagnosis, and were feasible in clinical settings.

Targeting autophagy in osteoporosis: From pathophysiology to potential therapy

Osteoporosis is a highly prevalent disorder characterized by the loss of bone mass and microarchitecture deterioration of bone tissue, attributed to various factors, including menopause (primary), aging (primary) and adverse effects of relevant medications (secondary). In recent decades, knowledge regarding the etiological mechanisms underpinning osteoporosis emphasizes that bone cellular homeostasis, including the maintenance of cell functions, differentiation, and the response to stress, is tightly regulated by autophagy, which is a cell survival mechanism for eliminating and recycling damaged proteins and organelles. With the important roles in the maintenance of cellular homeostasis and organ function, autophagy has emerged as a potential target for the prevention and treatment of osteoporosis. In this review, we update and discuss the pathophysiology of autophagy in normal bone cell life cycle and metabolism. Then, the alternations of autophagy in primary and secondary osteoporosis, and the accompanied pathological process are discussed. Finally, we discuss current strategies, limitations, and challenges involved in targeting relevant pathways and propose strategies by which such hurdles may be circumvented in the future for their translation into clinical validations and applications for the prevention and treatment of osteoporosis.

Biological basis of bone strength: anatomy, physiology and measurement

Understanding how bones are innately designed, robustly developed and delicately maintained through intricate anatomical features and physiological processes across the lifespan is vital to inform our assessment of normal bone health, and essential to aid our interpretation of adverse clinical outcomes affecting bone through primary or secondary causes. Accordingly this review serves to introduce new researchers and clinicians engaging with bone and mineral metabolism, and provide a contemporary update for established researchers or clinicians. Specifically, we describe the mechanical and non-mechanical functions of the skeleton; its multidimensional and hierarchical anatomy (macroscopic, microscopic, organic, inorganic, woven and lamellar features); its cellular and hormonal physiology (deterministic and homeostatic processes that govern and regulate bone); and processes of mechanotransduction, modelling, remodelling and degradation that underpin bone adaptation or maladaptation. In addition, we also explore commonly used methods for measuring bone metabolic activity or material features (imaging or biochemical markers) together with their limitations.

Nitrates Do Not Affect Bone Density or Bone Turnover in Postmenopausal Women: A Randomized Controlled Trial

Organic nitrates have been reported to have significant effects on bone mineral density (BMD) and bone turnover in previous clinical trials. However, results are inconsistent and some trials with strikingly positive results have been retracted because of scientific misconduct. As preparation for a potential fracture prevention study, we set out to determine the lowest effective dose and the most effective and acceptable nitrate preparation. We undertook a 1-year, double-blind, randomized, placebo-controlled trial of three different nitrate preparations and two different doses in osteopenic postmenopausal women, with a planned 1-year observational extension. The primary endpoint was change in BMD at the lumbar spine, and secondary endpoints included BMD changes at other sites, changes in bone turnover markers, and adverse events. A total of 240 eligible women who tolerated low-dose oral nitrate treatment in a 2-week run-in period were randomized to five different treatment groups or placebo. Over 12 months, there were no statistically significant between-group differences in changes in BMD at any site and no consistent differences in bone turnover markers. When the active treatment groups were pooled, there were also no differences in changes in BMD or bone turnover markers between nitrate treatment and placebo. Eighty-eight (27%) women withdrew during the run-in phase, with the majority because of nitrate-induced headache, and 41 of 200 (21%) women randomized to nitrate treatment withdrew or stopped study medication during the 1-year study compared with 1 of 40 (2.5%) in the placebo group. In summary, organic nitrates do not have clinically relevant effects on BMD or bone turnover in postmenopausal women and were poorly tolerated. These results call into question the validity of previous clinical research reporting large positive effects of nitrates on BMD and bone turnover. © 2020 American Society for Bone and Mineral Research.

The Belgian Bone Club 2020 guidelines for the management of osteoporosis in postmenopausal women

PURPOSE

To provide updated evidence-based guidelines for the management of osteoporosis in postmenopausal women in Belgium.

METHODS

The Belgian Bone Club (BBC) gathered a guideline developer group. Nine "Population, Intervention, Comparator, Outcome" (PICO) questions covering screening, diagnosis, non-pharmacological and pharmacological treatments, and monitoring were formulated. A systematic search of MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus was performed to find network meta-analyses, meta-analyses, systematic reviews, guidelines, and recommendations from scientific societies published in the last 10 years. Manual searches were also performed. Summaries of evidence were provided, and recommendations were further validated by the BBC board members and other national scientific societies' experts.

RESULTS

Of the 3840 references in the search, 333 full texts were assessed for eligibility, and 129 met the inclusion criteria. Osteoporosis screening using clinical risk factors should be considered. Patients with a recent (<2 years) major osteoporotic fracture were considered at very high and imminent risk of future fracture. The combination of bone mineral density measured by dual-energy X-ray absorptiometry and 10-year fracture risk was used to categorize patients as low or high risk. Patient education, the combination of weight-bearing and resistance training, and optimal calcium intake and vitamin D status were recommended. Antiresorptive and anabolic osteoporosis treatment should be considered for patients at high and very high fracture risk, respectively. Follow-up should focus on compliance, and patient-tailored monitoring should be considered.

CONCLUSION

BBC guidelines and 25 guideline recommendations bridge the gap between research and clinical practice for the screening, diagnosis, and management of osteoporosis.

Comparison of different calcium supplementation methods in patients with osteoporosis

The aim of the present study was to explore the clinical efficacy and safety of different methods of calcium supplementation in osteoporosis (OP). Patients with OP were divided into four groups, including the control, oral calcium supplementation, intravenous calcium supplementation and combined calcium supplementation groups. The duration of the calcium supplementation was 3-6 years. Medical records were collected and examined along with demographic data, the incidence of certain diseases and adverse reactions. All subjects in the three treatment groups exhibited statistically significant reductions in alkaline phosphatase (ALP) levels, visual analog score (VAS) and Oswestry Disability Index (ODI) compared with the respective pre-treatment values. Furthermore, compared with prior to treatment, the lumbar and hip bone mineral density (BMD) of patients receiving intravenous calcium supplementation was significantly increased. In addition, after treatment, the lumbar and hip BMD was significantly increased, whereas ALP levels, VAS and ODI were significantly decreased in the oral calcium supplementation group compared with the control group. Also, compared with the control and oral calcium supplementation groups, the BMD was significantly increased, whereas ALP, VAS, ODI, the rate of infection and tooth loss, the incidence of fragility fractures, joint replacement surgery, arrhythmia, lumbar disc herniation and cerebral infarction were significantly decreased in the two groups treated with intravenous calcium supplementation. The results of the present study may enable a better understanding of the effectiveness and safety of the different methods for supplementing calcium in OP.

Nutritional Support and Physical Modalities for People with Osteoporosis: Current Opinion

Osteoporosis is a vital healthcare issue among elderly people. During the aging process, a gradual loss of bone mass results in osteopenia and osteoporosis. Heritable factors account for 60%-80% of optimal bone mineralization, whereas modifiable factors such as nutrition, weight-bearing exercise, body mass, and hormonal milieu affect the development of osteopenia and osteoporosis in adulthood. Osteoporosis substantially increases the risk of skeletal fractures and further morbidity and mortality. The effective prevention of fractures by reducing the loss of bone mass is the primary goal for physicians treating people with osteoporosis. Other than pharmacologic agents, lifestyle adjustment, nutritional support, fall prevention strategies, exercise, and physical modalities can be used to treat osteoporosis or prevent further osteoporotic fracture. Each of these factors, alone or in combination, can be of benefit to people with osteoporosis and should be implemented following a detailed discussion with patients. This review comprises a systematic survey of the current literature on osteoporosis and its nonpharmacologic and nonsurgical treatment. It provides clinicians and healthcare workers with evidence-based information on the assessment and management of osteoporosis. However, numerous issues regarding osteoporosis and its treatment remain unexplored and warrant future investigation.

Adherence to the Mediterranean Diet and Bone Fracture Risk in Middle-Aged Women: A Case Control Study

The prevention of bone mass loss and related complications associated with osteoporosis is a significant public health issue. The Mediterranean diet (MD) is favorably associated with bone health, a potentially modifiable risk factor. The objective of this research was to determine MD adherence in a sample of women with and without osteoporosis. In this observational case-control study of 139 women (64 women with and 75 without osteoporosis) conducted in a primary-care health center in Girona (Spain), MD adherence, lifestyle, physical exercise, tobacco and alcohol consumption, pathological antecedents, and FRAX index scores were analyzed. Logistic multilinear regression modeling to explore the relationship between the MD and bone fracture risk indicated that better MD adherence was associated with a lower bone risk fracture. Non-pharmacological preventive strategies to reduce bone fracture risk were also reviewed to explore the role of lifestyle and diet in bone mass maintenance and bone fracture prevention.

Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines

We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.

Management of Reduced Bone Mineral Density in HIV: Pharmacological Challenges and the Role of Exercise

Low bone mineral density is becoming more common among people living with HIV following the use of current antiretroviral therapy drugs such as tenofovir. Although pharmacological therapies used to treat low bone mineral density are associated with adverse effects and may increase the pill burden in people living with HIV who are already burdened by antiretroviral therapy drugs, non-pharmacological strategies to prevent and treat reduced bone mineral density resulting from antiretroviral therapy drugs in people living with HIV have not been fully explored. Despite evidence that exercise is effective in increasing bone mineral density, effects of exercise on low bone mineral density resulting from antiretroviral therapy drugs in HIV infected individuals are still unknown. This review highlights gaps in the strategies used to manage reduced bone mineral density resulting from antiretroviral therapy drugs and focuses on exercise as an alternative or adjunctive strategy.

Warm needle acupuncture in primary osteoporosis management: a systematic review and meta-analysis

BACKGROUND

Warm needle acupuncture (WNA) is commonly used in primary osteoporosis (OP) management in China. The evidence of its effectiveness needs to be systematically reviewed.

OBJECTIVE

The aim of the meta-analysis was to evaluate whether using WNA alone or combined with conventional medicine benefits primary OP.

METHODS

PubMed, Embase, the Cochrane Central Register, Medline, China National Knowledge Infrastructure, Wanfang and VIP databases were searched from their inception through 30 June 2016. RCTs applying WNA independently or as an adjunct to conventional medicine, compared with conventional medicine alone, were included. Primary outcomes were bone mineral density (BMD) of the lumbar vertebrae, femoral neck, Ward's triangle and greater trochanter. The secondary outcome was chronic pain measured by VAS score. Meta-analysis was conducted using RevMan V.5.3 software.

RESULTS

Nine RCTs involving 572 participants were included. When WNA was used as an adjunct to conventional medicine, meta-analysis revealed a statistical difference in favour of increasing BMD of the lumbar vertebrae (mean difference (MD)=0.06, 95% CI 0.03 to 0.08, P<0.001). WNA increased BMD of the femoral neck (MD 0.14, 95% CI 0.08 to 0.21, P<0.001) and greater trochanter (MD 0.09, 95% CI 0.04 to 0.15, P<0.001) when used alone, and additionally decreased VAS scores (MD=-1.10, 95% CI -1.14 to -1.06, P<0.001) when used as an adjunct to conventional medicine. However, the safety of WNA was not specifically reported.

CONCLUSIONS

WNA may have beneficial effects on BMD and VAS scores of patients with primary OP. However, all included trials were at high risk of bias and of low quality. Further rigorous studies are needed to determine the effectiveness of WNA for primary OP treatment.

Rearing system affects prevalence of keel-bone damage in laying hens: a longitudinal study of four consecutive flocks

High flock-level prevalence of keel-bone fractures and deviations in laying hens are commonly reported across various housing systems; however, few longitudinal studies exist, especially for furnished and conventional cage systems. Load-bearing exercise improves bone strength and mineral composition in laying hens and has the potential to reduce keel-bone damage, especially if exercise is allowed during critical periods of bone growth throughout the pullet rearing phase. The objective of this study was to determine the prevalence of keel-bone damage in laying hens housed in furnished and conventional cages, and assess whether opportunities for exercise during the pullet rearing phase influenced the prevalence of keel-bone damage throughout the laying period. Four flock replicates of 588 Lohmann Selected Leghorn-Lite pullets/flock were reared in either conventional cages (Conv) or an aviary rearing system (Avi) and placed into conventional cages (CC), 30-bird furnished cages (FC-S) or 60-bird furnished cages (FC-L) for adult housing. Keel-bone status was determined by palpation at 30, 50, and 70 wk of age. Age (P < 0.001) and rearing system (P < 0.001) had an effect on the presence of keel-bone fractures. The presence of fractures increased with age, and hens raised in the Avi system had a lower percentage of fractures (41.6% ± 2.8 SE) compared to hens reared in the Conv system (60.3% ± 2.9 SE). Adult housing system did not have an effect on the percentage of keel fractures (P = 0.223). Age had an effect on the presence of deviations (P < 0.001), with deviations increasing with age. Rearing system (P = 0.218) and adult housing system (P = 0.539) did not affect the presence of deviations. Keel fractures and deviations were strongly associated with each other at all ages: 30 wk: (P < 0.001); 50 wk: (P < 0.001); and 70 wk: (P < 0.001). Increased opportunities for exercise provided by an aviary rearing system reduced the prevalence of keel-bone fractures through the end-of-lay.

Glucocorticoids, Inflammation and Bone

The current review on glucocorticoids (GCs), inflammation and bone is focused on three aspects: (1) the mutual effects between GCs, inflammation and bone in inflammatory rheumatic diseases, (2) current views on fracture risk assessment in patients using GCs and (3) non-pharmacological and pharmacological treatment to prevent fractures in GC-using patients with inflammatory rheumatic diseases. The use of GCs results in increased risk for fractures due to both direct and indirect negative effects of GCs on bone mass, and on bone and muscle strength. However, also the underlying inflammatory rheumatic disease is associated with the increased bone loss and fracture risk due to the chronic inflammation itself, and due to disability/immobility caused by active disease or joint destruction. The rapid and strong anti-inflammatory effect of GCs in patients with rheumatoid arthritis seems to balance the negative effects of GCs on bone in the early, active phase of the disease. Recently, an update of the American College of Rheumatology guidelines for prevention and treatment of GC-induced osteoporosis was published with renewed recommendations. To prevent fractures, general measures, including treatment of the underlying inflammatory disease adequately (even with GCs when indicated), a healthy lifestyle, including adequate calcium and vitamin D supplementation, and regular weight bearing exercises are important. In rheumatic patients with high fracture risk using GCs, especially when the cumulative dose is high and/or the underlying inflammatory disease is active, treatment with anti-osteoporotic drugs, usually an oral bisphosphonate, is indicated.

Dairy product consumption and risk of hip fracture: a systematic review and meta-analysis

BACKGROUND

Dairy product consumption may affect the risk of hip fracture, but previous studies have reported inconsistent findings. The primary aim of our meta-analysis was to examine and quantify the potential association of dairy product consumption with risk of hip fracture.

METHODS

We searched the databases of PubMed and EMBASE for relevant articles from their inception through April 17, 2017. The final analysis included 10 cohort studies and 8 case-control studies. Random-effects models were used to estimate the pooled risk. Subgroup and dose-response analyses were conducted to explore the relationships between the consumption of milk and the risk of hip fracture.

RESULTS

After pooling the data from the included studies, the summary relative risk (RR) for hip fracture for highest versus lowest consumption were 0.91 (95% CI: 0.74-1.12), 0.75 (95% CI: 0.66-0.86), 0.68 (95% CI: 0.61-0. 77), 1.02 (95% CI: 0.93-1.12) for milk, yogurt, cheese, and total dairy products in cohort studies, respectively. Higher milk consumption [Odds ratio (OR), 0.71, 95% CI: 0.55-0. 91] was associated with lower risk of hip fracture for highest versus lowest consumption in case-control studies. After quantifying the specific dose of milk, the summary RR/OR for an increased milk consumption of 200 g/day was 1.00 (95% CI: 0.94-1.07), and 0.89 (95%CI: 0.64-1.24) with significant heterogeneity for cohort and case-control studies, respectively; There was a nonlinear association between milk consumption and hip fracture risk in cohort, and case-control studies.

CONCLUSIONS

Our findings indicate that consumption of yogurt and cheese was associated with lower risk of hip fracture in cohort studies. However, the consumption of total dairy products and cream was not significantly associated with the risk of hip fracture. There was insufficient evidence to deduce the association between milk consumption and risk of hip fracture. A lower threshold of 200 g/day milk intake may have beneficial effects, whereas the effects of a higher threshold of milk intake are unclear.

Critical issues and current challenges in osteoporosis and fracture prevention. An overview of unmet needs

Osteoporosis is a silent disease with increasing prevalence due to the global ageing population. Decreased bone strength and bone quality is the hallmark of osteoporosis which leads to an increased risk of fragility fractures in elderly. It has been estimated that approximately ~50% of women will suffer during their lifetime from an osteoporotic fracture. This must be considered as a major health concern, as it has previously been established that fragility fracture has been associated with decreased quality of life due to increased disability, more frequent hospital admission and most importantly, osteoporotic fractures have been related to an augmented mortality risk. Anti-osteoporotic drugs are available for improving bone quality. Although there is access to these therapeutic options, there remain multiple unmet needs in the field of osteoporosis and fracture care, for example, the primary prevention of osteoporosis in young individuals (to reach a high peak bone mass), the optimization of the use of imaging techniques [dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA) and new techniques measuring bone quality], the use of nonmedical treatment options and surgical techniques of fracture healing. In this review, we will discuss topics that play a role in the occurrence and prevention of fractures, and we give an overview of and insight into the critical issues and challenges around osteoporosis and fracture prevention.

Systematic scoping review of patients' perceived needs of health services for osteoporosis

Health service planners, administrators and providers need to understand the patients' perspective of health services related to osteoporosis to optimise health outcomes. The aims of this study were to systematically identify and review the literature regarding patients' perceived health service needs relating to osteoporosis and osteopenia. A systematic scoping review was performed of publications in MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016). Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Aggregates of patients' perceived needs of osteoporosis health services were categorised. Thirty-three studies (19 quantitative and 14 qualitative) from 1027 were relevant. The following areas of perceived need emerged: (1) patients sought healthcare from doctors to obtain information and initiate management. They were dissatisfied with poor communication, lack of time and poor continuity of care. (2) Patients perceived a role for osteoporosis pharmacotherapy but were concerned about medication administration and adverse effects. (3) Patients believed that exercise and vitamin supplementation were important, but there is a lack of data examining the needs for other non-pharmacological measures such as smoking cessation and alcohol. (4) Patients wanted diagnostic evaluation and ongoing surveillance of their bone health. This review identified patients' needs for better communication with their healthcare providers. It also showed that a number of important cornerstones of therapy for osteoporosis, such as pharmacotherapy and exercise, are identified as important by patients, as well as ongoing surveillance of bone health. Understanding patients' perceived needs and aligning them with responsive and evidence-informed service models are likely to optimise patient outcomes.

Caffeine at a Moderate Dose Did Not Affect the Skeletal System of Rats with Streptozotocin-Induced Diabetes

Diabetes may lead to the development of osteoporosis. Coffee drinking, apart from its health benefits, is taken into consideration as an osteoporosis risk factor. Data from human and animal studies on coffee and caffeine bone effects are inconsistent. The aim of the study was to investigate effects of caffeine at a moderate dose on the skeletal system of rats in two models of experimental diabetes induced by streptozotocin. Effects of caffeine administered orally (20 mg/kg aily for four weeks) were investigated in three-month-old female Wistar rats, which, two weeks before the start of caffeine administration, received streptozotocin (60 mg/kg, intraperitoneally) alone or streptozotocin after nicotinamide (230 mg/kg, intraperitoneally). Bone turnover markers, mass, mineral density, histomorphometric parameters, and mechanical properties were examined. Streptozotocin induced diabetes, with profound changes in the skeletal system due to increased bone resorption and decreased bone formation. Although streptozotocin administered after nicotinamide induced slight increases in glucose levels at the beginning of the experiment only, slight, but significant unfavorable changes in the skeletal system were demonstrated. Administration of caffeine did not affect the investigated skeletal parameters of rats with streptozotocin-induced disorders. In conclusion, caffeine at a moderate dose did not exert a damaging effect on the skeletal system of diabetic rats.

Critical issues and current challenges in osteoporosis and fracture prevention. An overview of unmet needs

Osteoporosis is a silent disease with increasing prevalence due to the global ageing population. Decreased bone strength and bone quality is the hallmark of osteoporosis which leads to an increased risk of fragility fractures in elderly. It has been estimated that approximately ~50% of women will suffer during their lifetime from an osteoporotic fracture. This must be considered as a major health concern, as it has previously been established that fragility fracture has been associated with decreased quality of life due to increased disability, more frequent hospital admission and most importantly, osteoporotic fractures have been related to an augmented mortality risk. Anti-osteoporotic drugs are available for improving bone quality. Although there is access to these therapeutic options, there remain multiple unmet needs in the field of osteoporosis and fracture care, for example, the primary prevention of osteoporosis in young individuals (to reach a high peak bone mass), the optimization of the use of imaging techniques [dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA) and new techniques measuring bone quality], the use of nonmedical treatment options and surgical techniques of fracture healing. In this review, we will discuss topics that play a role in the occurrence and prevention of fractures, and we give an overview of and insight into the critical issues and challenges around osteoporosis and fracture prevention.

Meta-analysis of dual-energy computed tomography virtual non-calcium imaging to detect bone marrow edema

OBJECTIVE

This meta-analysis aimed to evaluate the accuracy of dual-energy CT (DECT) virtual non-calcium (VNC) imaging for the detection of bone marrow edema (BME).

METHODS

A systematic literature search up to March 2017 was performed to find relevant original studies. Two reviewers independently selected studies, assessed literature quality, and extracted data. Pooled sensitivity, specificity, area under receiver operating characteristic (AUROC) curve, and other measures of DECT accuracy for detecting BME were calculated using random effects models. Risk of heterogeneity was assessed for the appropriateness of meta-analysis.

RESULTS

Fourteen studies involving 2205 regions of vertebrae, hips, knees, and ankles were included. To evaluate the accuracy of BME detection using DECT, calculations were performed to obtain a pooled sensitivity of 0.812 (95% confidence interval [CI], 0.780-0.841) and specificity of 0.951 (95% CI, 0.940-0.960). The AUROC value was 0.9635. The major potential cause of heterogeneity was bone position. No significant publication bias was present.

CONCLUSION

DECT VNC imaging gives very good diagnostic performance for BME detection and will likely be an important and common modality for acute assessment in the future.

Whole body vibration versus magnetic therapy on bone mineral density in elderly osteoporotic individuals

BACKGROUND

Osteoporosis usually develops gradually and progresses without significant signs and symptoms. It is one of the most common musculoskeletal conditions associated with aging.

OBJECTIVES

To evaluate the effects of whole body vibration (WBV) or magnetic therapy in addition to standard pharmacological treatment on bone mineral density (BMD) in elderly individuals being treated for osteoporosis.

METHODS

Eighty-five participants, 60-75 years of age, were randomly divided into three groups. All three groups received the same standard pharmacological treatment comprised of vitamin D, calcium, and alendronate sodium. In Group I, thirty participants were also exposed to WBV for 25 minutes in each session with two sessions per week for 4 months. In Group II, thirty participants were exposed to magnetic therapy for 50 minutes in each session with two sessions per week for 4 months. In Group III, twenty-five participants received only pharmacological treatment. Dual-energy X-ray absorptiometry was used to measure BMD of the lumbar spine and femoral heads before and after interventions. Venus blood sample was drawn for analysis of calcium and vitamin D.

RESULTS

An ANOVA test detected significant (p< 0.05) differences in BMD after treatment among the three groups with no significant difference was detected between patients receiving WBV and magnetic therapy. Statistical t-tests detected significant (p< 0.05) increases in BMD after application of WBV or magnetic therapy in combination with pharmacological treatment, but no significant increase after pharmacological treatment alone.

CONCLUSIONS

Addition of either WBV or magnetic therapy to standard pharmacological treatment for osteoporosis significantly increased BMD in elderly subjects. No significant difference in effectiveness was detected between these two alternative therapy modalities. Consequently, either WBV or magnetic therapy could be effectively applied in conjunction with pharmacological treatment to increase BMD in elderly osteoporotic patients.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Biological Silicon Stimulates Collagen Type 1 and Osteocalcin Synthesis in Human Osteoblast-Like Cells Through the BMP-2/Smad/RUNX2 Signaling Pathway

Silicon is essential for bone formation. A low-silicon diet leads to bone defects, and numerous animal models have demonstrated that silicon supplementation increases bone mineral density (BMD) and reduces bone fragility. However, the exact mechanism of this action has not been characterized. In this study, we aimed to determine the role of biological silicon in the induction of osteoblast differentiation and the possible underlying mechanism. We examined whether orthosilicic acid promotes collagen type 1 (COL-1) and osteocalcin synthesis through the bone morphogenetic protein-2 (BMP-2)/Smad1/5/runt-related transcription factor 2 (RUNX2) signaling pathway by investigating its effect in vitro at several concentrations on COL-1 and osteocalcin synthesis in human osteosarcoma cell lines (MG-63 and U2-OS). The expression of relevant proteins was detected by Western blotting following exposure to noggin, an inhibitor of BMP-2. In MG-63 cells, immunofluorescence methods were applied to detect changes in the expression of BMP-2, phosphorylated Smad1/5 (P-Smad1/5), and RUNX2. Furthermore, rat bone mesenchymal stem cells (BMSCs) were used to determine the effect of orthosilicic acid on osteogenic differentiation. Exposure to 10 μM orthosilicic acid markedly increased the expression of BMP-2, P-Smad1/5, RUNX2, COL-1, and osteocalcin in osteosarcoma cell lines. Enhanced ALP activity and the formation of mineralized nodules were also observed under these conditions. Furthermore, preconditioning with noggin inhibited the silicon-induced upregulation of P-Smad1/5, RUNX2, and COL-1 expression. In conclusion, the BMP-2/Smad1/5/RUNX2 signaling pathway participates in the silicon-mediated induction of COL-1 and osteocalcin synthesis, and orthosilicic acid promotes the osteogenic differentiation of rat BMSCs.

Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline

Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non-invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence-based physiotherapy care to people with CF in Australia and New Zealand.

The population attributable risk of nutrition and lifestyle on hip fractures

INTRODUCTION

Norway is among the countries with the highest incidence of hip fractures, and how to reduce this incidence is a major public health concern.

MATERIALS AND METHODS

The population attributable risk (PAR), which measures the portion of hip fracture incidences in the population that can be attributed to an exposure if there is a causal relationship, was assessed for the exposure to excessive alcohol consumption, being underweight, low calcium from dairy products, low physical activity and current tobacco smoking. The risk ratio (RR) of the exposures summarized from systematic reviews and meta-analyses, as well as their prevalence from national statistics or Norwegian population-based studies, were used to estimate PARs.

RESULTS

Low physical activity and current tobacco smoking had the highest RR for hip fractures, with 1.65 (95% CI 1.50-1.81) and 1.52 (95% CI 1.41-1.63). Low physical activity had the highest prevalence in the population (27.4%) and the highest PAR (0.151), followed by tobacco smoking (PAR = 0.081) and excessive alcohol consumption (PAR = 0.01). By comparison, being underweight and low calcium from dairy products had negligible PAR estimates.

CONCLUSIONS

From a public health perspective, increased daily physical activity is the most promising intervention to reduce the incidence of hip fractures. Reduced smoking and alcohol consumption are of relevance, but other health risks related to these exposures are of greater public health concern. Low body weight and nutritional calcium from dairy products seem to be of less importance.

A summary of the Malaysian Clinical Guidance on the management of postmenopausal and male osteoporosis, 2015

AIM

This Clinical Guidance is aimed to help practitioners assess, diagnose and manage their patients with osteoporosis (OP), using the best available evidence.

METHODS

A literature search using PubMed (MEDLINE) and The Cochrane Library identified all relevant articles on OP and its assessment, diagnosis and treatment, from 2011, to update from the 2012 edition. The studies were assessed and the level of evidence assigned. For each statement, studies with the highest level of evidence were used to frame the recommendation.

RESULTS

This article summarizes the diagnostic and treatment pathways for postmenopausal and male OP, while addressing the risk-benefit ratio for OP treatment. Recognising the limitation of only depending on bone mineral density in assessing fracture risk, a move to assess 10 year fracture risk using tools such as FRAX, is recommended as a guide to decision-making on when to start treatment. A re-evaluation was done of the position of calcium supplementation and on the importance of vitamin D. There has been concern about the potential adverse effects of the long-term usage of bisphosphonates, which have been discussed fully. Algorithms for the management of postmenopausal and male OP have been updated.

CONCLUSIONS

Adequate intake of calcium (1000 mg from both diet and supplements) and vitamin D (800 IU) daily remain important adjuncts in the treatment of OP. However, in confirmed OP, pharmacological therapy with anti-resorptives is the mainstay of treatment in both men and postmenopausal women. Patients need to be regularly assessed while on medication and treatment adjusted as appropriate.

Effects of Yogasanas on osteoporosis in postmenopausal women

Background:

Osteoporosis is commonly encountered by postmenopausal women. There is an increased need for a low cost and efficient treatment alternative to address this population.

Aims:

To study the effects of integrated yoga on bone mineral density (BMD) in postmenopausal women with osteoporosis.

Settings and Designs:

Experimental pre-post study conducted in a community setting.

Materials and Methods:

30 females in the age group of 45–62 years suffering from postmenopausal osteoporosis with a dual-energy X-ray absorptiometry (DEXA) score of ≤−2.5 underwent a 6 months fully supervised yoga session. All the participants completed the study. Pretraining and posttraining BMD was calculated. Outcome measure: DEXA score at the lumbar spine.

Statistical Analysis:

The study was statistically analyzed using paired t-test to see the significance of pretraining and posttraining effects of a yoga session.

Results:

Improvement in T-score of DEXA scan of −2.55 ± 0.25 at posttraining as compared to a pretraining score of −2.69 ± 0.17.

Conclusions:

Integrated yoga is a safe mode of physical activity which includes weight bearing as well as not weight bearing asanas, Pranayama, and suryanamaskar, all of which helps induce improvement in BMD in postmenopausal osteoporotic females.

Marrow adipogenesis and bone loss that parallels estrogen deficiency is slowed by low-intensity mechanical signals

Ovariectomized mice were used to assess the ability of low-intensity vibrations to protect bone microarchitecture and marrow composition. Results indicate that low-intensity vibrations (LIV), introduced 2 weeks postsurgery, slows marrow adipogenesis in OVX mice but does not restore the bone within the period studied. However, immediate application of LIV partially protects quality.

INTRODUCTION

The aim of this study was to evaluate consequences of estrogen depletion on bone marrow (BM) phenotype and bone microarchitecture, and effects of mechanical signals delivered as LIV on modulating these changes.

METHODS

LIV (0.3 g, 90 Hz) was applied to C57BL/6 mice immediately following ovariectomy or 2 weeks postestrogen withdrawal for 2 (ST-LIV) or 6 weeks (LT-LIV), respectively. Sham-operated age-matched controls (ST-AC, LT-AC) and ovariectomized controls (ST-OVX, LT-OVX) received sham LIV treatment. Bone microstructure was evaluated through μCT and BM adipogenesis through histomorphometry, serum markers, and genes expression analysis.

RESULTS

LT-OVX increased BM adipogenesis relative to LT-AC (+136 %, p ≤ 0.05), while LT-LIV introduced for 6w suppressed this adipose encroachment (-55 %, p ≤ 0.05). In parallel with the fatty marrow, LT-OVX showed a marked loss of trabecular bone, -40 % (p ≤ 0.05) in the first 2 weeks following ovariectomy compared to LT-AC. Application of LT-LIV for 6w following this initial 2w bone loss failed to restore the lost trabeculae but did initiate an anabolic response as indicated by increased serum alkaline phosphatase (+26 %, p ≤ 0.05). In contrast, application of LIV immediately following ovariectomy was more efficacious in the protection of trabecular bone, with a +29 % (p > 0.05) greater BV/TV compared to ST-OVX at the 2w time period.

CONCLUSIONS

LIV can mitigate adipocyte accumulation in OVX marrow and protect it by favoring osteoblastogenesis over adipogenesis. These data also emphasize the rapidity of bone loss with OVX and provide perspective in the timing of treatments for postmenopausal osteoporosis where sooner is better than later.

Changes in biomarkers of bone turnover in an aripiprazole add-on or switching study

BACKGROUND

The association between mental illness and osteoporosis and fractures is particularly pronounced in psychotic disorders. Antipsychotic use has previously been described to affect bone density.

METHOD

A 52-week follow-up of patients switched to aripiprazole or with aripiprazole added on, conducting a specific analysis of markers of bone turnover: urinary NTX (a biomarker of bone resorption) and serum BSAP (a biomarker of bone formation). Baseline and serial measurements of bone markers NTX, BSAP and of hormones prolactin, oestrogen and testosterone were done at weeks 0 and 1, 2, 6, 12, 26 and 52, respectively.

RESULTS

NTX concentration reduced over time but this did not reach significance in the whole group (log-NTX: β=-0.0012, p=0.142). For BSAP the addition of or replacement with aripiprazole produced a significant reduction (log-BSAP: β=-0.00039, p=0.002). Analysis with prolactin similarly showed a significant reduction (log-prolactin: β=-0.0024, p<0.001); other hormones did not change significantly. Sensitivity analysis to compare the switchers to aripiprazole versus the "add-on" showed that the former group had a significant reduction in NTX.

CONCLUSIONS

We found that switching to aripiprazole was associated with changes in molecular biomarkers of bone resorption, indicating a more favourable profile for bone health.

Effects of Dairy Products Consumption on Health: Benefits and Beliefs--A Commentary from the Belgian Bone Club and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases

Dairy products provide a package of essential nutrients that is difficult to obtain in low-dairy or dairy-free diets, and for many people it is not possible to achieve recommended daily calcium intakes with a dairy-free diet. Despite the established benefits for bone health, some people avoid dairy in their diet due to beliefs that dairy may be detrimental to health, especially in those with weight management issues, lactose intolerance, osteoarthritis, rheumatoid arthritis, or trying to avoid cardiovascular disease. This review provides information for health professionals to enable them to help their patients make informed decisions about consuming dairy products as part of a balanced diet. There may be a weak association between dairy consumption and a possible small weight reduction, with decreases in fat mass and waist circumference and increases in lean body mass. Lactose intolerant individuals may not need to completely eliminate dairy products from their diet, as both yogurt and hard cheese are well tolerated. Among people with arthritis, there is no evidence for a benefit to avoid dairy consumption. Dairy products do not increase the risk of cardiovascular disease, particularly if low fat. Intake of up to three servings of dairy products per day appears to be safe and may confer a favourable benefit with regard to bone health.

Effects of thirty elements on bone metabolism

The human skeleton, made of 206 bones, plays vital roles including supporting the body, protecting organs, enabling movement, and storing minerals. Bones are made of organic structures, intimately connected with an inorganic matrix produced by bone cells. Many elements are ubiquitous in our environment, and many impact bone metabolism. Most elements have antagonistic actions depending on concentration. Indeed, some elements are essential, others are deleterious, and many can be both. Several pathways mediate effects of element deficiencies or excesses on bone metabolism. This paper aims to identify all elements that impact bone health and explore the mechanisms by which they act. To date, this is the first time that the effects of thirty minerals on bone metabolism have been summarized.

Hip Protectors: Are They Worth it?

Hip fractures are one of the most serious conditions in frail elderly subjects, greatly increasing morbidity and mortality, and decreasing healthy life years. Since their first introduction on the market, hip protectors have been revealed to be a potential preventive measure for hip fractures, in addition to other well-known recognized medical interventions and rehabilitation procedures. However, randomized controlled trials have given contradictory results regarding their efficacy. Moreover, little data are available on the cost effectiveness of hip protectors. Adherence is a major problem in assessing the effectiveness of hip protectors in preventing fractures. Indeed, there is a lack of general consensus on a standard definition and quantitative objective estimation of adherence to hip protectors, along with still scarce evidence on specific interventions on how to ameliorate it. From what is known so far, it seems reasonable to advise the use of hip protectors in aged care facilities, since recent pooled analyses have suggested their efficacy in this setting. The introduction of sensors combined with hip protectors will probably address this issue, both for monitoring and optimizing compliance, especially in elderly people. In the meantime, new, well-designed studies following specific guidelines are strongly encouraged and needed. In particular, studies in community-dwelling elderly individuals at high risk of first or further fragility fractures are required. The optimization of the tested devices in a preclinical setting according to international standard biomechanical testing is necessary.