Vertebral fracture assessment (VFA) by lateral DXA scanning may be cost-effective when used as part of fracture liaison services or primary care screening

Bone-active drugs in premenopausal women with breast cancer under hormone-deprivation therapies

BACKGROUND

Bone health management in premenopausal women with breast cancer (BC) under hormone-deprivation therapies (HDTs) is often challenging, and the effectiveness of bone-active drugs is still unknown.

METHODS

This retrospective multicenter study included 306 premenopausal women with early BC undergoing HDTs. Bone mineral density (BMD) and morphometric vertebral fractures (VFs) were assessed 12 months after HDT initiation and then after at least 24 months.

RESULTS

After initial assessment, bone-active drugs were prescribed in 77.5% of women (151 denosumab 60 mg/6 months, 86 bisphosphonates). After 47.0 ± 20.1 months, new VFs were found in 16 women (5.2%). Vertebral fracture risk was significantly associated with obesity (odds ratio [OR] 3.87, P = .028), family history of hip fractures or VFs (OR 3.21, P = .040], chemotherapy-induced menopause (OR 6.48, P < .001), preexisting VFs (OR 25.36, P < .001), baseline T-score less than or equal to -2.5 standard deviation (SD) at any skeletal site (OR 4.14, P = .036), and changes at lumbar and total hip BMD (OR 0.94, P = .038 and OR 0.88, P < .001, respectively). New VFs occurred more frequently in women untreated compared to those treated with bone-active drugs (14/69, 20.8% vs 2/237, 0.8%; P < .001) and the anti-fracture effectiveness remained significant after correction for BMI (OR 0.03; P < .001), family history of fractures (OR 0.03; P < .001), chemotherapy-induced menopause (OR 0.04; P < .001), and preexisting VFs (OR 0.01; P < .001).

CONCLUSIONS

Premenopausal women under HDTs are at high risk of VFs in relationship with high BMI, densitometric diagnosis of osteoporosis, preexisting VFs, and family history of osteoporotic fractures. Vertebral fractures in this setting might be effectively prevented by bisphosphonates or denosumab.

Diagnosis and therapeutic approach to bone health in patients with hypopituitarism

The results of many studies in recent years indicate a significant impact of pituitary function on bone health. The proper function of the pituitary gland has a significant impact on the growth of the skeleton and the appearance of sexual dimorphism. It is also responsible for achieving peak bone mass, which protects against the development of osteoporosis and fractures later in life. It is also liable for the proper remodeling of the skeleton, which is a physiological mechanism managing the proper mechanical resistance of bones and the possibility of its regeneration after injuries. Pituitary diseases causing hypofunction and deficiency of tropic hormones, and thus deficiency of key hormones of effector organs, have a negative impact on the skeleton, resulting in reduced bone mass and susceptibility to pathological fractures. The early appearance of pituitary dysfunction, i.e. in the pre-pubertal period, is responsible for failure to achieve peak bone mass, and thus the risk of developing osteoporosis in later years. This argues for the need for a thorough assessment of patients with hypopituitarism, not only in terms of metabolic disorders, but also in terms of bone disorders. Early and properly performed treatment may prevent patients from developing the bone complications that are so common in this pathology. The aim of this review is to discuss the physiological, pathophysiological, and clinical insights of bone involvement in pituitary disease.

Denosumab improves trabecular bone score in relationship with decrease in fracture risk of women exposed to aromatase inhibitors

PURPOSE

Trabecular bone score (TBS) is a gray-level textural metric that has shown to correlate with risk of fractures in several forms of osteoporosis. The value of TBS in predicting fractures and the effects of bone-active drugs on TBS in aromatase inhibitors (AIs)-induced osteoporosis are still largely unknown. The primary objective of this retrospective study was to assess the effects of denosumab and bisphosphonates (BPs) on TBS and vertebral fractures (VFs) in women exposed to AIs.

METHODS

241 consecutive women (median age 58 years) with early breast cancer undergoing treatment with AIs were evaluated for TBS, bone mineral density (BMD) and morphometric VFs at baseline and after 18-24 months of follow-up. During the study period, 139 women (57.7%) received denosumab 60 mg every 6 months, 53 (22.0%) BPs, whereas 49 women (20.3%) were not treated with bone-active drugs.

RESULTS

Denosumab significantly increased TBS values (from 1.270 to 1.323; P < 0.001) accompanied by a significant decrease in risk of VFs (odds ratio 0.282; P = 0.021). During treatment with BPs, TBS did not significantly change (P = 0.849) and incidence of VFs was not significantly different from women untreated with bone-active drugs (P = 0.427). In the whole population, women with incident VFs showed higher decrease in TBS vs. non-fractured women (P = 0.003), without significant differences in changes of BMD at any skeletal site.

CONCLUSIONS

TBS variation predicts fracture risk in AIs treated women. Denosumab is effective to induce early increase of TBS and reduction in risk of VFs.

Skeletal complications in acromegaly

Hypersecretion of growth hormone (GH) is rare and typically results from a pituitary functional tumor - somatotropinoma. It leads to excessive linear bone growth and manifests as gigantism if occurring in childhood and adolescence, before the closure of epiphyses or as a acromegaly in adulthood. The excess of GH impacts bone metabolism directly as well as indirectly through increased insulin-like growth factor 1 (IGF-1). In acromegaly as a consequence of overproduction of GH and IFG-1 and the influence of these hormones on bone osteoblasts, bone metabolism, growth and density increase. However, bone turnover is accelerated causing impaired bone microstructure and strength, which may lead to increased risk of vertebral fractures irrespective of normal bone mineral density. Apart from the changes in bone architecture, acromegaly also results in a degenerative joint disease of a different nature than primary osteoarthritis. Moreover, acromegaly leads to cardiovascular, metabolic and respiratory complications, and thus significantly impairs the quality of life. In this review, authors summarize the pathophysiology, diagnosis, and treatment of bone and joint disease in acromegaly.

Routine Use of Lateral Vertebral Assessment With DXA Scan for Detection of Silent But Debilitating Vertebral Fractures

PURPOSE OF THE REPORT

Reduced bone mineral density is a major public health dilemma with high prevalence. Vertebral fracture (VF) is an independent risk factor for fragility fracture. Lateral vertebral assessment (LVA) in dual-energy x-ray absorptiometry is a reliable, low-radiation, accurate, and cost-effective method for VF assessment.

PATIENTS AND METHODS

Five hundred seventy-five scans of oncologic and nononcologic patients were retrospectively reviewed irrespective of age or sex. Patients' symptoms, bone mineral density, and risk factors were also evaluated. Scans in which LVA was not acquired or had previously known VFs were excluded.

RESULTS

The mean age of patients was 66 ± 11.5 years. Eleven percent of patients had VFs on LVA, of which 7 were excluded due to known VFs. Ten percent had new VFs, most of whom were women (n = 42). The most common risk factor was secondary osteoporosis in women and rheumatoid arthritis in men. Sixty-eight percent of the patients had solitary fractures, whereas 32% had multiple fractures. Most of these patients had underlying osteopenia (n = 19). FRAX was calculated twice: once with the history of personal fracture marked and the other time unmarked as these would not have been discovered if LVA was not acquired. Statistically significant mean percent difference of 5.4% was found in probability of major osteoporotic fracture and 2.1% in the mean risk of hip fracture.

CONCLUSIONS

In our population, 10% patients had unsuspected VFs on LVA in dual-energy x-ray absorptiometry scan. Most of these were nononcologic patients with associated risk factors. Based on the FRAX tool, there is a significant difference in the 10-year risk of fracture when unsuspected fractures discovered on LVA are marked.

Effect of Degarelix Administration on Bone Health in Prostate Cancer Patients Without Bone Metastases. The Blade Study

CONTEXT

As patients are now living with prostate cancer for longer, the long-term impact of hormonal treatment on bone health is an increasingly debated subject.

OBJECTIVE

To characterize the changes in bone mineral density (BMD) and bone turnover markers after degarelix administration in prostate cancer patients without bone metastases. To explore the predictive role of body composition on treatment induced bone loss.

METHODS

BMD and body composition (lean body mass, fat body mass, and appendicular mass index [ALMI]) were assessed by dual X-ray absorptiometry on study entry and after 12 months of degarelix therapy. Alkaline phosphate (ALP) and C-terminal telopeptide of type I collagen (CTX) were assessed at baseline, and 6 and 12 months.

RESULTS

Twenty-nine patients entered the study. Degarelix administration was associated with a significant decrease in BMD after 12 months (2.4% reduction from baseline at lumbar spine). Serum CTX and ALP increased significantly (median increase from baseline 99% and 19.3%, respectively). An inverse correlation was observed between ALMI and CTX, but not ALP, at both baseline (Pearson r = -0.62, P < .0001) and month 12 (Pearson r = -0.41, P = .032). Moreover, a significant inverse correlation between changes in ALMI and CTX at 12 months (Pearson r = -0.43, P = .019) and a direct relationship between changes of ALMI and ALP (Pearson r = 0.44, P = .016) during degarelix therapy were observed.

CONCLUSION

Degarelix administration is associated with a significant decrease in BMD and increase in bone turnover markers. ALMI is a promising predictor of bone loss in prostate cancer patients receiving androgen deprivation therapy, and ALMI changes during therapy are associated with bone turnover derangement favoring bone quality alterations.

Real-World Effectiveness of Denosumab and Bisphosphonates on Risk of Vertebral Fractures in Women with Breast Cancer Undergoing Treatment with Aromatase Inhibitors

Bone-active drugs are recommended to protect the skeleton from detrimental actions of aromatase inhibitors (AIs). However, most of literature data are focused on bone mineral density (BMD), whereas data on fractures are scant. The aim of this prospective study was to investigate the real-life effectiveness of denosumab, oral bisphosphonates (BPs) and intravenous zoledronate on risk of vertebral fractures (VFs) induced by AIs. 567 consecutive women (median age 62 years, range 28-83) with early breast cancer undergoing treatment with AIs were evaluated for morphometric VFs and BMD at baseline and after 18-24 months of follow-up. After enrollment, 268 women (47.3%) started denosumab 60 mg subcutaneously every 6 months, 115 (20.3%) BPs (59 with oral BPs and, 56 with intravenous zoledronate 5 mg/12 months), whereas 184 women (32.5%) were not treated with bone-active drugs for several reasons. During follow-up, 54 women (9.5%) developed incident VFs in association with age of subjects (P &lt; 0.001), baseline FRAX scores for major fractures (P &lt; 0.001) and hip fractures (P = 0.003), pre-existing VFs (P &lt; 0.001), change in BMD at lumbar spine (P = 0.015), femoral neck (P = 0.003) and total hip (P &lt; 0.001). Risk of VFs was higher in subjects who were untreated as compared to those treated with bone-active drugs (32/184 vs. 22/383; P &lt; 0.001). Specifically, fracture risk was significantly decreased by denosumab [odds ratio (OR) 0.22; P &lt; 0.001] and zoledronate (OR 0.27; P = 0.035), but not by oral BPs (P = 0.317). These data suggest that in real-world clinical practice, denosumab and zoledronate can reduce AI-related risk of VFs after only 24 months of treatment.

Skeletal disorders associated with the growth hormone-insulin-like growth factor 1 axis

Growth hormone (GH) and insulin-like growth factor 1 (IGF1) are important regulators of bone remodelling and metabolism and have an essential role in the achievement and maintenance of bone mass throughout life. Evidence from animal models and human diseases shows that both GH deficiency (GHD) and excess are associated with changes in bone remodelling and cause profound alterations in bone microstructure. The consequence is an increased risk of fractures in individuals with GHD or acromegaly, a condition of GH excess. In addition, functional perturbations of the GH-IGF1 axis, encountered in individuals with anorexia nervosa and during ageing, result in skeletal fragility and osteoporosis. The effect of interventions used to treat GHD and acromegaly on the skeleton is variable and dependent on the duration of the disease, the pre-existing skeletal state, coexistent hormone alterations (such as those occurring in hypogonadism) and length of therapy. This variability could also reflect the irreversibility of the skeletal structural defect occurring during alterations of the GH-IGF1 axis. Moreover, the effects of the treatment of GHD and acromegaly on locally produced IGF1 and IGF binding proteins are uncertain and in need of further study. This Review highlights the pathophysiological, clinical and therapeutic aspects of skeletal fragility associated with perturbations in the GH-IGF1 axis.

Prediction of vertebral fractures in cancer patients undergoing hormone deprivation therapies: reliability of who fracture risk assessment tool (frax) and bone mineral density in real-life clinical practice

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In females under estrogen-deprivation therapies, risk of vertebral fractures was associated with FRAX score for major fractures, with the best therapeutic threshold of 6.5%.

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In males under androgen-deprivation therapy, risk of vertebral fractures was high when BMD T-score was lower than −1.0 SD or when subjects were treated with abiraterone.

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High body mass index was an independent risk factor for vertebral fractures in males exposed to androgen-deprivation therapy.

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In the setting of hormonal deprivation therapies, FRAX and BMD thresholds were lower than those used in post-menopausal osteoporosis and primary male osteoporosis.

Background and Objective

Prediction of fractures in cancer survivors exposed to hormone-deprivation therapies (HDTs) is a challenge since bone loss is rapid and severe, and determinants of fractures in this setting are still largely unknown. In this study we investigated reliability of the WHO Fracture Risk Assessment Tool (FRAX) and bone mineral density (BMD) to identify subjects developing vertebral fractures during HDTs.

Design

Five-hundred-twenty-seven consecutive subjects (429 females with breast cancer, 98 males with prostate cancer; median age 61 years), under HDTs for at least 6 months, were evaluated for vertebral fractures by a radiological and morphometric approach, in relationship with FRAX score, body mass index (BMI), BMD, age and duration of HDTs.

Results

Vertebral fractures were found in 140 subjects (26.6%) and spine deformity index was significantly associated with duration of HDTs (rho 0.38; p < 0.001). Only in females, vertebral fractures were significantly associated with FRAX score for major fractures [OR 1.08; P < 0.001]. The best cut-off of FRAX score for major fractures, as calculated by receiving operating characteristic (ROC) analysis was 6.35%. In males, however, vertebral fractures were significantly and independently associated with BMI ≥ 25 Kg/m² (OR 17.63; P < 0.001), BMD T-score below −1.0 SD at any skeletal site (OR 7.79; P < 0.001) and gonadotropin-releasing hormone agonists (GnRHa) plus abiraterone treatment (OR 11.51; P = 0.001).

Conclusions

FRAX and BMD may be useful for predicting vertebral fractures in subjects undergoing HDTs, but the thresholds seem to be lower than those used in the general population. High BMI is a determinant of vertebral fractures in males under HDT.

Update on vertebral fractures in pituitary diseases: from research to clinical practice

Derangement of pituitary hormone axes can induce changes in bone remodeling and metabolism with possible alterations in bone microarchitectural structure and increased susceptibility to fractures. Vertebral fractures (VFs), which are a hallmark of skeletal fragility, have been described in a very large number of patients with pituitary diseases. These fractures are clinically relevant, since they predispose to further fractures and may negatively impact on patients' quality of life. However, the management of skeletal fragility and VFs in the specific setting of pituitary diseases is a challenge, since the awareness for this disease is still low, prediction of VFs is uncertain, the diagnosis of VFs cannot be solely based on a clinical approach and also needs a radiological and morphometric approach, the risk of fractures may not be decreased via treatment of pituitary hormone disorders, and the effectiveness of bone-active drugs in this setting is not always evidence-based. This review is an update on skeletal fragility in patients with pituitary diseases, with a focus on clinical and therapeutic aspects concerning the management of VFs.

Current Applications and Selected Technical Details of Dual-Energy X-Ray Absorptiometry

The application of dual-energy X-ray absorptiometry (DXA) examinations in the assessment of bone mineral density (BMD) in the lumbar spine, hip, and forearm is the basic diagnostic method for recognition of osteoporosis. The constant development of DXA technique is due to the aging of societies and the increasing importance of osteoporosis as a public health problem. In order to assess the degree of bone demineralization in patients with hyperparathyroidism, forearm DXA examination is recommended. The vertebral fracture assessment (VFA) of the thoracic and lumbar spine, performed by a highly-skilled technician, is an interesting alternative to the X-ray examination. The DXA total body examination can be useful in the evaluation of fat redistribution among patients after bariatric surgery, in patients infected with HIV and receiving antiretroviral therapy, and in patients with metabolic diseases and suspected to have sarcopenia. The assessment of visceral adipose tissue (VAT) and detection of abdominal aortic calcifications may be useful in the prediction of cardiovascular events. The positive effect of anti-resorptive therapy may affect some parameters of DXA hip structure analysis (HSA). Long-term anti-resorptive therapy, especially with the use of bisphosphonates, may result in changes in the DXA image, which may herald atypical femur fractures (AFF). Reduction of the periprosthetic BMD in the DXA measurements can be used to estimate the likelihood of loosening the prosthesis and periprosthetic fractures. The present review aims to present current applications and selected technical details of DXA.

Osteoporosis: Recent Recommendations and Positions of the American Society for Bone and Mineral Research and the International Society for Clinical Densitometry

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Osteoporosis is common in orthopaedic patients, not only in those sustaining fragility fractures but also in patients ≥50 years old who are having elective orthopaedic surgery.

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The American Society for Bone and Mineral Research (ASBMR) has developed consensus-based recommendations for secondary fracture prevention for all patients who are ≥65 years old with a hip or spine fracture.

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The ASBMR encourages orthopaedic surgeons to "Own the Bone," by beginning prevention of a secondary fracture during hospitalization for a fragility fracture, if practicable, and arranging follow-up for continued bone health care after discharge.

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The International Society for Clinical Densitometry (ISCD) recognized that many poor outcomes and complications of elective orthopaedic surgery are related to osteoporosis.

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The ISCD used an evidence-based approach to create official positions to identify which patients ≥50 years old who are having elective orthopaedic surgery should undergo assessment of bone health and how this should be performed.

Skeletal health in patients with differentiated thyroid carcinoma

Osteoporosis and fractures are important comorbidities in patients with differentiated thyroid cancer (DTC), with potential negative impact on quality of life and survival. The main determinant of skeletal fragility in DTC is the thyrotropin (TSH)-suppressive therapy, which is commonly recommended to prevent disease's recurrence, especially in patients with structural incomplete response after thyroid surgery and radio-iodine therapy. TSH-suppressive therapy can stimulate bone resorption with consequent bone loss, deterioration of bone microstructure and high risk of fragility fractures. The skeletal effects of TSH-suppressive therapy may be amplified when thyroid cancer cells localize to the skeleton inducing alterations in bone remodelling, impairment of bone structure and further increase in risk of fractures. The management of skeletal fragility in DTC may be challenging, since prediction of fractures is a matter of uncertainty and data on effectiveness and safety of bone-active agents in this clinical setting are still scanty. This review deals with pathophysiological, clinical and therapeutic aspects of skeletal fragility of patients with DTC.

Vertebral fracture assessment (VFA) for osteoporosis screening in US postmenopausal women: is it cost-effective?

Vertebral fracture assessment (VFA) is cost-effective when it was incorporated in the routine screening for osteoporosis in community-dwelling women aged ≥ 65 years, which support guidelines, such as the National Osteoporosis Foundation (NOF) for the diagnostic use of VFA as an important addition to fracture risk assessment.

INTRODUCTION

To evaluate the cost-effectiveness of VFA as a screening tool to reduce future fracture risk in US community-dwelling women aged ≥ 65 years.

METHODS

An individual-level state-transition cost-effectiveness model from a healthcare perspective was constructed using derived data from published literature. The time horizon was lifetime. Five screening strategies were compared, including no screening at all, central dual-energy X-ray absorptiometry (DXA) only, VFA only, central DXA followed by VFA if the femoral neck T-score (FN-T) ≤ - 1.5, or if the FN-T ≤ - 1.0. Various initiation ages and rescreening intervals were evaluated. Oral bisphosphonate treatment for 5-year periods was assumed. Incremental cost-effectiveness ratios (2017 US dollars per quality-adjusted life-year (QALY) gained) were used as the outcome measure.

RESULTS

The incorporation of VFA slightly increased life expectancy by 0.1 years and reduced the number of subsequent osteoporotic fractures by 3.7% and 7.7% compared with using DXA alone and no screening, respectively, leading to approximately 30 billion dollars saved. Regardless of initiation ages and rescreening intervals, central DXA followed by VFA if the FN-T ≤ - 1.0 was most cost-effective ($40,792 per QALY when the screening is initiated at age 65 years and with rescreening every 5 years). Results were robust to change in VF incidence and medication costs.

CONCLUSION

In women aged ≥ 65 years, VFA is cost-effective when it was incorporated in routine screening for osteoporosis. Our findings support the National Osteoporosis Foundation (NOF) guidelines for the diagnostic use of VFA as an important addition to fracture risk assessment.

Vertebral fracture assessment (VFA) in patients over 50 years of age with a non-severe peripheral fracture

The prevalence of unknown vertebral fractures evaluated by systematic vertebral fracture assessment (VFA) was 21% in patients over 50 years of age who suffered from a recent low-trauma non-severe peripheral fracture. The outcome of VFA resulted in changes in the management of osteoporosis.

INTRODUCTION

The aim of this study was to evaluate the utility of VFA in detecting vertebral fractures (VFs) in patients over 50 years of age, who suffered from a recent low-trauma non-severe peripheral fracture.

METHODS

This was an observational, single-center, cross-sectional study conducted in patients over 50 years of age, who presented a recent low-trauma non-severe peripheral fracture and were identified by the Fracture Liaison Service (FLS) of Amiens University Hospital between December 2017 and March 2019. VFA was interpreted by two trained rheumatologists providing a consensual reading using Genant semi-quantitative assessment.

RESULTS

Of the 359 eligible patients, 114 patients (31.8%) were included (mean age 65.6 ± 8.4 years; 89.5% female). Twenty-four patients (21%) had one or more VF diagnosed by VFA. The total number of VF diagnosed by VFA was 30: 20 VF (66.7%) grade 1, 7 VF (23.3%) grade 2, and 3 VF (10%) grade 3. Among the 24 patients with at least one prevalent VF diagnosed by VFA, 18 patients had an osteoporosis medication adaptation after the VFA results (16 osteoporosis medication initiation and 2 treatment intensification), and 6 patients would have had an osteoporosis medication even without the VFA results (66.7% versus 33.3% respectively, p < 0.001). Of the 51 patients receiving an osteoporosis medication after DXA and VFA, 18 patients (35.3%) had a change in the management of osteoporosis after knowing the outcome of VFA. All the VFs diagnosed by VFA were unknown before. We did not evidence any threshold (age, T-score, height loss) below which no VF was detected.

CONCLUSIONS

Our study demonstrates the usefulness of systematic VFA to detect prevalent VF in patients over 50 years of age who suffer from a recent non-severe peripheral fracture.

Identification of prevalent vertebral fractures using Vertebral Fracture Assessment (VFA) in asymptomatic postmenopausal women: A systematic review and meta-analysis

BACKGROUND

Vertebral fracture (VF) is the most common osteoporotic fracture in postmenopausal women, although most VFs are subclinical. Prevalent VFs are a significant predictor of subsequent fracture and therefore, identification of VF improves the identification of those with high fracture risk. The aim of present study was to systematically review the literature that assessed the prevalence of VF in asymptomatic postmenopausal women, using Vertebral Fracture Assessment (VFA) by dual-energy X-ray absorptiometry.

METHOD

Medline, Web of Science and Cochrane databases were searched between Jan 1st, 2000 and Jan 31st, 2018, for publications in English that reported the prevalence of VFA-detected VF in asymptomatic postmenopausal women. We also searched for reports, conference papers and grey literature. Reviewers screened studies for eligibility and extracted data for included studies. Random effects meta-analyses were performed to calculate the prevalence of VF. The presence of publication bias was assessed using funnel plots by precision and Egger's Test of the Intercept.

RESULTS

A total of 1777 articles were identified, 94 studies were fully reviewed and 28 studies (n = 25,418) met the inclusion criteria and were analyzed. More than two thirds of the studies were cross-sectional and the sample size varied widely across the studies (from 63 to 5156). The mean age ranged from 59.5 to 86.2 years old. The prevalence of osteoporosis and osteopenia varied between 6-57.0% and 25.1-58.9%, respectively. However, among women who had prevalent VFs, up to 43% had osteopenia and as many as 32% had normal bone density. The weighted pooled prevalence of VFA-detected VF in asymptomatic women was 28% (95% CI: 23%-32%).

CONCLUSION

VFA is able to identify prevalent VF in asymptomatic postmenopausal women. The use of VFA identified an average of 28% of asymptomatic women with VFs, many of whom did not have a diagnosis of osteoporosis. Implementation of VFA as a routine screening tool may detect high risk women. Detection of VF might lead to pharmacological treatment in individuals who may not otherwise be treated.

Impact of mild and moderate/severe vertebral fractures on physical activity: a prospective study of older women in the UK

Little is known about the long-term impact of vertebral fractures on physical activity. There is also uncertainty over the clinical significance of mild vertebral fracture. We showed that women with moderate/severe but not mild vertebral fracture do less walking duration and housework than those without fracture after 5.4 years of follow-up.

INTRODUCTION

Little is known about the long-term impact of vertebral fractures on physical activities. There is also uncertainty over the clinical significance of mild fracture. Therefore, the aim of this study was to evaluate the prospective association between vertebral fracture and future physical activity.

METHODS

This is a 5-year prospective study of a mixed community and secondary care cohort of women aged > 50 from the UK. Vertebral fractures were identified at baseline on radiographs or DXA-based Vertebral Fracture Assessment by a Quantitative Morphometric approach and defined as moderate/severe (≥ 25% height decrease) or mild (20-24.9% height decrease). Physical activity data were collected 5.4 years later by self-completion questionnaires. Multivariable logistic regression was used to determine the association between presence of fracture and various physical activities while adjusting for potential confounders.

RESULTS

Two hundred eighty-six women without, 58 with mild, and 69 with moderate/severe fracture were recruited. Those with mild and moderate/severe fracture were older than women without fracture and had more concomitant diseases at baseline. At 5.4 years follow-up, women with moderate/severe fracture self-reported shorter walking duration compared to those without fracture, even after adjusting for potential confounders (OR 2.96, 95%CI 1.11-7.88, P = 0.030). No independent association was seen between the presence of mild fractures and reduced physical activity at follow-up.

CONCLUSION

This is the first study of older women from the UK that explored the prospective association between vertebral fracture and physical activity duration. Moderate/severe fractures were associated with reduced walking duration. Mild fractures had no impact on future physical ability.

Guidelines for the management of osteoporosis and fragility fractures

The purpose of this document, a result of the harmonisation and revision of Guidelines published separately by the SIMFER, SIOMMMS/SIR, and SIOT associations, is to provide practical indications based on specific levels of evidence and various grades of recommendations, drawn from available literature, for the management of osteoporosis and for the diagnosis, prevention, and treatment of fragility fractures. These indications were discussed and formally approved by the delegates of the Italian Scientific Associations involved in the project (SIE, SIGG, SIMFER, SIMG, SIMI, SIOMMMS, SIR, and SIOT).

Pituitary Diseases and Bone

Neuroendocrinology of bone is a new area of research based on the evidence that pituitary hormones may directly modulate bone remodeling and metabolism. Skeletal fragility associated with high risk of fractures is a common complication of several pituitary diseases such as hypopituitarism, Cushing disease, acromegaly, and hyperprolactinemia. As in other forms of secondary osteoporosis, pituitary diseases generally affect bone quality more than bone quantity, and fractures may occur even in the presence of normal or low-normal bone mineral density as measured by dual-energy X-ray absorptiometry, making difficult the prediction of fractures in these clinical settings. Treatment of pituitary hormone excess and deficiency generally improves skeletal health, although some patients remain at high risk of fractures, and treatment with bone-active drugs may become mandatory. The aim of this review is to discuss the physiological, pathophysiological, and clinical insights of bone involvement in pituitary diseases.

Vertebral fracture assessment in patients presenting with a non-hip non-vertebral fragility fracture: experience of a UK Fracture Liaison Service

Twenty-five percent of patients with a non-hip non-vertebral fragility fracture have an undiagnosed vertebral fracture detected by vertebral fracture assessment during bone densitometric assessment. The prevalence of an undiagnosed vertebral fracture is higher in older people, and they are more likely to have multiple vertebral fractures.

PURPOSE

Most vertebral fragility fractures (VFF) have no history of trauma. Vertebral fracture assessment (VFA) during dual energy x-ray absorptiometry (DXA) can be used to detect these VFFs. This study aims to identify the prevalence of undiagnosed VFF in patients presenting with a non-hip non-vertebral fragility fracture.

METHODS

Patients identified by the fracture liaison service (FLS) of a large UK university hospital presenting with a non-hip non-vertebral fragility fracture were evaluated from 1 January 2012 to 30 September 2015. Local protocol identified those that would proceed for VFA. Data was collected on patient characteristics, fracture details, bone mineral density (BMD) measurements and VFA results.

RESULTS

Five hundred sixty-seven patients (mean (SD) age, 72 (9.4) years) of mostly women (88.3%) had a VFA performed as part of their DXA assessment. One hundred forty-three patients (25.2%) were identified to have a vertebral fracture, of whom 57.3% of them had one fracture. 49.5% of those with vertebral fractures had BMD measurements diagnostic of osteoporosis. Mean (SD) age was higher in those with vertebral fractures compared to those without; 74.9 (8.3) years vs 70.4 (9.5) years, p < 0.00. Those aged 75 years and over were more likely to have multiple fractures than those younger than 75 years (16.3 vs 4%, p = 0.01).

CONCLUSION

A quarter of patients presenting with a non-hip non-vertebral fragility fracture have an undiagnosed vertebral fracture. Older people are more likely to have vertebral fractures and more likely to have multiple fractures. VFA during bone densitometric assessment can further aid stratifying future fracture risk.

Do subjective memory complaints predict falls, fractures and healthcare utilization? A two-year prospective study based on a cohort of older women recruited from primary care

OBJECTIVE

A proportion of older individuals report subjective memory complaints (SMCs), which can predict the development of cognitive impairment and dementia. Previous studies based on secondary care suggest that SMC is also associated with other adverse health consequences, including falls, fractures and increased healthcare utilization. In this study, we aimed to establish whether similar findings are observed in the wider population.

METHODS

Prospective analysis of the Cohort for Skeletal Health in Bristol and Avon, a population-based cohort recruited from primary care, was carried out. Data were collected by self-completion questionnaire at baseline and 2 years. SMC was assessed at baseline. Fractures, measures of falls, mobility and healthcare utilization were assessed 2 years later. A random 5% subsample of data was validated against electronic general practitioner records. Logistic regression was used to identify independent associations, following adjustment for a range of confounders assessed at baseline.

RESULTS

Data were available on 3184 women. Three hundred and fifty participants (11.0%) reported SMC. They were older (73.3 ± 4.5 vs 72.0 ± 4.2 years) and less mobile compared with those not reporting SMC. SMCs at baseline were associated with an increased risk of upper limb fractures over the following 2 years (OR 1.72, 95% CI 1.02-2.90). SMCs were also associated with an increased risk of falls (OR 1.83, 95% CI 1.41-2.38) and increased healthcare utilization (OR for hospital appointments 2.20, 95% CI 1.26-3.86). No association was observed with bone mineral density at any site.

CONCLUSIONS

Subjective memory complaints are important markers of adverse health outcomes and should prompt interventions to reduce fractures such as physiotherapy-led fall reduction programmes. Copyright © 2016 John Wiley & Sons, Ltd.

Spinal radiographs in those with back pain-when are they appropriate to diagnose vertebral fractures?

The presence of an osteoporotic vertebral fracture improves fracture risk assessment and may change management, so it is vital for healthcare professionals to assess patients for the presence or absence of these fractures. This may be particularly important in the presence of back pain. However, the correlation between low back symptoms and spinal imaging results is poor and the pathophysiology of most low back pain is not known, leading to a common conclusion that spinal radiographs are not appropriate for the assessment of back pain. For individual patients with back pain, spinal radiographs should be considered if they have certain features in the history and examination. As well as the traditional risk factors for osteoporosis, self-reported descriptives of back pain and novel physical examination findings have been shown to make the presence of vertebral fractures more likely. Systematic approaches have the potential to improve bone health across the population but need to be targeted to be cost-effective. Spinal radiographs should be considered for individual older patients with back pain if they have certain additional features in the history and examination.

The Clinical Utility of Vertebral Fracture Assessment in Predicting Fractures

Vertebral fracture (VF) is the most common type of osteoporotic fracture. VFs are associated with diminished quality of life and high morbidity and mortality. The presence of a VF, especially a recent one, is an important risk factor for developing another fracture. However, most VFs are not clinically recognized. VF assessment by dual-energy X-ray absorptiometry is a convenient, low-cost, low-radiation, reliable method to identify VFs during bone mineral density measurement. The finding of a previously unrecognized VF may change the diagnostic classification, assessment of fracture risk, and treatment strategies. This paper focuses on the utility of VF assessment in clinical practice.

Bone and Joint Disorders in Acromegaly

Acromegaly is a chronic, progressive disease caused by a growth hormone (GH)-producing pituitary adenoma, resulting in elevated GH and insulin-like growth factor 1 concentrations. Following appropriate therapy (surgery, radiotherapy and/or medical treatment), many systemic GH-induced comorbid conditions improve considerably. Unfortunately, despite biochemical control, acromegaly patients suffer from a high prevalence of late manifestations of transient GH excess, significantly impairing their quality of life. In this overview article, we summarize the pathophysiology, diagnosis, clinical picture, disease course and management of skeletal complications of acromegaly, focusing on vertebral fractures and arthropathy.

Choosing the tool for osteoporosis risk prediction

PURPOSE OF REVIEW

Predicting fracture risk is a major challenge because it allows the prevention of major osteoporotic fracture in high-risk populations. With the aging of the population, this matter will become of even greater importance. In recent years, novel clinical, biochemical, and imaging tools have been developed to improve the assessment of fracture risk.

RECENT FINDINGS

The present review summarizes novel clinical strategies, Dual energy X-ray absorptiometry (DXA)-derived tools, imaging techniques, and biochemical markers that have been developed recently to improve fracture risk prediction.

SUMMARY

DXA and clinical fracture risk prediction tools are preferential markers of fracture risk. Clinical fracture risk alone might be used if DXA facilities are unavailable. The fracture risk assessment tool may be used in osteoporosis consultation in many countries. Other tools may be used soon after more studies are performed, particularly trabecular bone score, quantitative ultrasound, bone turnover markers. Specific factors for example falls, hip axis length, vertebral fracture assessment could be used in individual patients. This may significantly improve the clinical decision-making.