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Huo S, Tang X, Chen W, Gan D, Guo H, Yao Q, Liao R, Huang T, Wu J, Yang J, Xiao G, Han X. Epigenetic regulations of cellular senescence in osteoporosis. Ageing Res Rev 2024; 99:102235. [PMID: 38367814 DOI: 10.1016/j.arr.2024.102235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/27/2024] [Accepted: 02/13/2024] [Indexed: 02/19/2024]
Abstract
Osteoporosis (OP) is a prevalent age-related disease that is characterized by a decrease in bone mineral density (BMD) and systemic bone microarchitectural disorders. With age, senescent cells accumulate and exhibit the senescence-associated secretory phenotype (SASP) in bone tissue, leading to the imbalance of bone homeostasis, osteopenia, changes in trabecular bone structure, and increased bone fragility. Cellular senescence in the bone microenvironment involves osteoblasts, osteoclasts, and bone marrow mesenchymal stem cells (BMSCs), whose effects on bone homeostasis are regulated by epigenetics. Therefore, the epigenetic regulatory mechanisms of cellular senescence have received considerable attention as potential targets for preventing and treating osteoporosis. In this paper, we systematically review the mechanisms of aging-associated epigenetic regulation in osteoporosis, emphasizing the impact of epigenetics on cellular senescence, and summarize three current methods of targeting cellular senescence, which is helpful better to understand the pathogenic mechanisms of cellular senescence in osteoporosis and provides strategies for the development of epigenetic drugs for the treatment of osteoporosis.
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Affiliation(s)
- Shaochuan Huo
- Shenzhen Hospital of Guangzhou University of Chinese Medicine (Futian), Shenzhen 518000, China; Shenzhen Research Institute of Guangzhou University of Traditional Medicine (Futian), Shenzhen 518000, China
| | - Xinzheng Tang
- Shenzhen Hospital of Guangzhou University of Chinese Medicine (Futian), Shenzhen 518000, China; Shenzhen Research Institute of Guangzhou University of Traditional Medicine (Futian), Shenzhen 518000, China
| | - Weijian Chen
- Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Donghao Gan
- Department of Biochemistry, School of Medicine, Shenzhen Key Laboratory of Cell Microenvironment, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Southern University of Science and Technology, Shenzhen 518055, China
| | - Hai Guo
- Liuzhou Traditional Chinese Medicine Hospital (Liuzhou Zhuang Medical Hospital), Liuzhou 545001, China
| | - Qing Yao
- Department of Biochemistry, School of Medicine, Shenzhen Key Laboratory of Cell Microenvironment, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Southern University of Science and Technology, Shenzhen 518055, China
| | - Rongdong Liao
- Department of Orthopaedics, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Tingting Huang
- Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Junxian Wu
- Shenzhen Hospital of Guangzhou University of Chinese Medicine (Futian), Shenzhen 518000, China
| | - Junxing Yang
- Shenzhen Hospital of Guangzhou University of Chinese Medicine (Futian), Shenzhen 518000, China; Shenzhen Research Institute of Guangzhou University of Traditional Medicine (Futian), Shenzhen 518000, China.
| | - Guozhi Xiao
- Department of Biochemistry, School of Medicine, Shenzhen Key Laboratory of Cell Microenvironment, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Southern University of Science and Technology, Shenzhen 518055, China.
| | - Xia Han
- Shenzhen Hospital of Guangzhou University of Chinese Medicine (Futian), Shenzhen 518000, China; Shenzhen Research Institute of Guangzhou University of Traditional Medicine (Futian), Shenzhen 518000, China.
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Szyszko JA, Aldieri A, La Mattina AA, Viceconti M. Phantomless calibration of CT scans for hip fracture risk prediction in silico: Comparison with phantom-based calibration. PLoS One 2024; 19:e0305474. [PMID: 38875268 PMCID: PMC11178222 DOI: 10.1371/journal.pone.0305474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/30/2024] [Indexed: 06/16/2024] Open
Abstract
Finite element models built from quantitative computed tomography images rely on element-wise mapping of material properties starting from Hounsfield Units (HU), which can be converted into mineral densities upon calibration. While calibration is preferably carried out by scanning a phantom with known-density components, conducting phantom-based calibration may not always be possible. In such cases, a phantomless procedure, where the scanned subject's tissues are used as a phantom, is an interesting alternative. The aim of this study was to compare a phantom-based and a phantomless calibration method on 41 postmenopausal women. The proposed phantomless calibration utilized air, adipose, and muscle tissues, with reference equivalent mineral density values of -797, -95, and 38 mg/cm3, extracted from a previously performed phantom-based calibration. A 9-slice volume of interest (VOI) centred between the femoral head and knee rotation centres was chosen. Reference HU values for air, adipose, and muscle tissues were extracted by identifying HU distribution peaks within the VOI, and patient-specific calibration was performed using linear regression. Comparison of FE models calibrated with the two methods showed average relative differences of 1.99% for Young's modulus1.30% for tensile and 1.34% for compressive principal strains. Excellent correlations (R2 > 0.99) were identified for superficial maximum tensile and minimum compressive strains. Maximum normalised root mean square relative error (RMSRE) values settled at 4.02% for Young's modulus, 2.99% for tensile, and 3.22% for compressive principal strains, respectively. The good agreement found between the two methods supports the adoption of the proposed methodology when phantomless calibration is needed.
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Affiliation(s)
- Julia A Szyszko
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Industrial Engineering, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Alessandra Aldieri
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
| | - Antonino A La Mattina
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Industrial Engineering, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Marco Viceconti
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Industrial Engineering, Alma Mater Studiorum-University of Bologna, Bologna, Italy
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Jung Y, Ay B, Cyr SM, Tognoni CM, Klovdahl K, Matthias J, Cui Q, Brooks DJ, Bouxsein ML, Carreras I, Dedeoglu A, Bastepe M. Amyloid-β neuropathology induces bone loss in male mice by suppressing bone formation and enhancing bone resorption. Bone Rep 2024; 21:101771. [PMID: 38725879 PMCID: PMC11078651 DOI: 10.1016/j.bonr.2024.101771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
Alzheimer's disease (AD) and osteoporosis often coexist in the elderly. Although observational studies suggest an association between these two diseases, the pathophysiologic link between AD and skeletal health has been poorly defined. We examined the skeletal phenotype of 5xFAD mice, an AD model with accelerated neuron-specific amyloid-β accumulation causing full-blown AD phenotype by the age of 8 months. Micro-computed tomography indicated significantly lower trabecular and cortical bone parameters in 8-month-old male, but not female, 5xFAD mice than sex-matched wild-type littermates. Dynamic histomorphometry revealed reduced bone formation and increased bone resorption, and quantitative RT-PCR showed elevated skeletal RANKL gene expression in 5xFAD males. These mice also had diminished body fat percentage with unaltered lean mass, as determined by dual-energy X-ray absorptiometry (DXA), and elevated Ucp1 mRNA levels in brown adipose tissue, consistent with increased sympathetic tone, which may contribute to the osteopenia observed in 5xFAD males. Nevertheless, no significant changes could be detected between male 5xFAD and wild-type littermates regarding the serum and skeletal concentrations of norepinephrine. Thus, brain-specific amyloid-β pathology is associated with osteopenia and appears to affect both bone formation and bone resorption. Our findings shed new light on the pathophysiologic link between Alzheimer's disease and osteoporosis.
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Affiliation(s)
- Younghun Jung
- The Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA 02118, USA
| | - Birol Ay
- The Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Sajin M. Cyr
- The Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Christina M. Tognoni
- Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA 02118, USA
| | - Kaitlin Klovdahl
- The Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Julia Matthias
- The Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Qiuxia Cui
- The Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Daniel J. Brooks
- The Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
| | - Mary L. Bouxsein
- The Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
| | - Isabel Carreras
- Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA 02118, USA
- Department of Biochemistry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Alpaslan Dedeoglu
- Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA 02118, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, MA 02114, USA
| | - Murat Bastepe
- The Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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Pennington Z, Mikula AL, Lakomkin N, Martini M, Pinter ZW, Shafi M, Hamouda A, Bydon M, Clarke MJ, Freedman BA, Krauss WE, Nassr AN, Sebastian AS, Fogelson JL, Elder BD. Bone Quality as Measured by Hounsfield Units More Accurately Predicts Proximal Junctional Kyphosis than Vertebral Bone Quality Following Long-Segment Thoracolumbar Fusion. World Neurosurg 2024; 186:e584-e592. [PMID: 38588791 DOI: 10.1016/j.wneu.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/31/2024] [Accepted: 04/01/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVE To compare the prognostic power of Hounsfield units (HU) and Vertebral Bone Quality (VBQ) score for predicting proximal junctional kyphosis (PJK) following long-segment thoracolumbar fusion to the upper thoracic spine (T1-T6). METHODS Vertebral bone quality around the upper instrumented vertebrae (UIV) was measured using HU on preoperative CT and VBQ on preoperative MRI. Spinopelvic parameters were also categorized according to the Scoliosis Research Society-Schwab classification. Univariable analysis to identify predictors of the occurrence of PJK and survival analyses with Kaplan-Meier method and Cox regression were performed to identify predictors of time to PJK (defined as ≥10° change in Cobb angle of UIV+2 and UIV). Sensitivity analyses showed thresholds of HU < 164 and VBQ > 2.7 to be most predictive for PJK. RESULTS Seventy-six patients (mean age 66.0 ± 7.0 years; 27.6% male) were identified, of whom 15 suffered PJK. Significant predictors of PJK were high postoperative pelvic tilt (P = 0.038), high postoperative T1-pelvic angle (P = 0.041), and high postoperative PI-LL mismatch (P = 0.028). On survival analyses, bone quality, as assessed by the average HU of the UIV and UIV+1 was the only significant predictor of time to PJK (odds ratio [OR] 3.053; 95% CI 1.032-9.032; P = 0.044). VBQ measured using the UIV, UIV+1, UIV+2, and UIV-1 vertebrae approached, but did not reach significance (OR 2.913; 95% CI 0.797-10.646; P = 0.106). CONCLUSIONS In larger cohorts, VBQ may prove to be a significant predictor of PJK following long-segment thoracolumbar fusion. However, Hounsfield units on CT have greater predictive power, suggesting preoperative workup for long-segment thoracolumbar fusion benefits from computed tomography versus magnetic resonance imaging alone to identify those at increased risk of PJK.
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Affiliation(s)
- Zach Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| | - Anthony L Mikula
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikita Lakomkin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Martini
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachariah W Pinter
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mahnoor Shafi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle J Clarke
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William E Krauss
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmad N Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arjun S Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy L Fogelson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Benjamin D Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Zheng Q, Wang D, Lin R, Li Z, Chen Y, Chen R, Zheng C, Xu W. Effects of circulating inflammatory proteins on osteoporosis and fractures: evidence from genetic correlation and Mendelian randomization study. Front Endocrinol (Lausanne) 2024; 15:1386556. [PMID: 38757000 PMCID: PMC11097655 DOI: 10.3389/fendo.2024.1386556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/16/2024] [Indexed: 05/18/2024] Open
Abstract
Objective There is a controversy in studies of circulating inflammatory proteins (CIPs) in association with osteoporosis (OP) and fractures, and it is unclear if these two conditions are causally related. This study used MR analyses to investigate the causal associations between 91 CIPs and OP and 9 types of fractures. Methods Genetic variants data for CIPs, OP, and fractures were obtained from the publicly available genome-wide association studies (GWAS) database. We used inverse variance weighted (IVW) as the primary analysis, pleiotropy, and heterogeneity tests to analyze the validity and robustness of causality and reverse MR analysis to test for reverse causality. Results The IVW results with Bonferroni correction indicated that CXCL11 (OR = 1.2049; 95% CI: 1.0308-1.4083; P = 0.0192) can increase the risk of OP; IL-4 (OR = 1.2877; 95% CI: 1.1003-1.5070; P = 0.0016), IL-7 (OR = 1.2572; 95% CI: 1.0401-1.5196; P = 0.0180), IL-15RA (OR = 1.1346; 95% CI: 1.0163-1.2668; P = 0.0246), IL-17C (OR = 1.1353; 95% CI: 1.0272-1.2547; P = 0.0129), CXCL10 (OR = 1.2479; 95% CI: 1.0832-1.4377; P = 0.0022), eotaxin/CCL11 (OR = 1.1552; 95% CI: 1.0525-1.2678; P = 0.0024), and FGF23 (OR = 1.9437; 95% CI: 1.1875-3.1816; P = 0.0082) can increase the risk of fractures; whereas IL-10RB (OR = 0.9006; 95% CI: 0.8335-0.9730; P = 0.0080), CCL4 (OR = 0.9101; 95% CI: 0.8385-0.9878; P = 0.0242), MCP-3/CCL7 (OR = 0.8579; 95% CI: 0.7506-0.9806; P = 0.0246), IFN-γ [shoulder and upper arm (OR = 0.7832; 95% CI: 0.6605-0.9287; P = 0.0049); rib(s), sternum and thoracic spine (OR = 0.7228; 95% CI: 0.5681-0.9197; P = 0.0083)], β-NGF (OR = 0.8384; 95% CI: 0.7473-0.9407; P = 0.0027), and SIRT2 (OR = 0.5167; 95% CI: 0.3296-0.8100; P = 0.0040) can decrease fractures risk. Conclusion Mendelian randomization (MR) analyses indicated the causal associations between multiple genetically predicted CIPs and the risk of OP and fractures.
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Affiliation(s)
- Qingcong Zheng
- Department of Spinal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Du Wang
- Arthritis Clinical and Research Center, Peking University People’s Hospital, Beijing, China
| | - Rongjie Lin
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhechen Li
- Department of Spinal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuchao Chen
- Department of Paediatrics, Fujian Provincial Hospital South Branch, Fuzhou, China
| | - Rongsheng Chen
- Department of Spinal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Chunfu Zheng
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Weihong Xu
- Department of Spinal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Klein MJ. Non-neoplastic bone, joint, and soft tissue pathology: What every pathologist should know. Hum Pathol 2024; 147:15-57. [PMID: 38237872 DOI: 10.1016/j.humpath.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/12/2024]
Abstract
The diagnosis of bone and soft tissue tumors is a skill which requires experience across multiple disciplines while their incidence is small. By contrast, the numbers of patients with non-tumorous diseases of bones, soft tissues, and joints dwarfs primary tumors by several orders of magnitude. The ability to successfully diagnose non-neoplastic diseases requires a knowledge of bone development, structure, remodeling, imaging, and tissue processing. This review summarizes the alterations of bones, joints, and to a lesser extent soft tissues that are encountered in the practice of everyday surgical pathology.
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Affiliation(s)
- Michael J Klein
- Professor of Pathology and Laboratory Medicine, Weill Cornell Medical College. Pathologist-in-Chief Emeritus and Attending Pathologist, Hospital for Special Surgery, USA.
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7
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Chen J, Sun Q, Yin W. Th17 Cell-Related Gene Biomarkers in Osteoporosis: Comprehensive Bioinformatics Analysis and In Vivo Validation. Horm Metab Res 2024; 56:373-380. [PMID: 37977205 DOI: 10.1055/a-2196-7811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The interaction between the bone and immune systems has a major role in osteoporosis regulation. However, the infiltration of T helper 17 (Th17) cells and their associated genes in osteoporosis remains unclear. The GSE35959 dataset was obtained from the Gene Expression Omnibus (GEO) database, and the Immune Cell Abundance Identifier (ImmuCellAI) program was used to evaluate the abundance of 24 immune cell types, including Th17 cells. Differential analysis and relevance analysis were performed to identify differentially expressed Th17 cell-related genes (DETh17RGs) in osteoporosis. The potential functions of DETh17RGs were analyzed using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways enrichment. Hub DETh17RGs were obtained through comprehensive analysis using Weighted Gene Co-Expression Network Analysis (WGCNA) and the CytoHubba plug-in algorithm. The expression levels of hub genes were validated using additional osteoporosis datasets. Additionally, the transcript levels of Hub genes in a mice model of osteoporosis were examined using quantitative PCR (qPCR). 464 DETh17RGs were identified in this study, with 421 genes showing positive associations and 43 genes showing negative associations. Among these, seven genes (CD44, TGFB1, ACTN4, ARHGDIA, ESR1, TLN1, FLNA) were considered as Hub DETh17RGs. The qPCR transcript levels of hub DETh17RGs in a mice model of osteoporosis exhibited consistent expression trends with the bioinformatics analysis. This research enhances our understanding of the molecular mechanisms involving Th17 cells in the development of osteoporosis and contributes to the discovery of potential biomarkers.
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Affiliation(s)
- Jianxing Chen
- Department of Joint Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qifeng Sun
- Department of Joint Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wenzhe Yin
- Department of Joint Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, China
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Dai GC, Wang H, Ming Z, Lu PP, Li YJ, Gao YC, Shi L, Cheng Z, Liu XY, Rui YF. Heterotopic mineralization (ossification or calcification) in aged musculoskeletal soft tissues: A new candidate marker for aging. Ageing Res Rev 2024; 95:102215. [PMID: 38325754 DOI: 10.1016/j.arr.2024.102215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/21/2024] [Accepted: 02/01/2024] [Indexed: 02/09/2024]
Abstract
Aging can lead to various disorders in organisms and with the escalating impact of population aging, the incidence of age-related diseases is steadily increasing. As a major risk factor for chronic illnesses in humans, the prevention and postponement of aging have become focal points of research among numerous scientists. Aging biomarkers, which mirror molecular alterations at diverse levels in organs, tissues, and cells, can be used to monitor and evaluate biological changes associated with aging. Currently, aging biomarkers are primarily categorized into physiological traits, imaging characteristics, histological features, cellular-level alterations, and molecular-level changes that encompass the secretion of aging-related factors. However, in the context of the musculoskeletal soft tissue system, aging-related biological indicators primarily involve microscopic parameters at the cellular and molecular levels, resulting in inconvenience and uncertainty in the assessment of musculoskeletal soft tissue aging. To identify convenient and effective indicators, we conducted a comprehensive literature review to investigate the correlation between ectopic mineralization and age-related changes in the musculoskeletal soft tissue system. Here, we introduce the concept of ectopic mineralization as a macroscopic, reliable, and convenient biomarker for musculoskeletal soft tissue aging and present novel targets and strategies for the future management of age-related musculoskeletal soft tissue disorders.
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Affiliation(s)
- Guang-Chun Dai
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Hao Wang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Zhang Ming
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Pan-Pan Lu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Ying-Juan Li
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Yu-Cheng Gao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Liu Shi
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Zhang Cheng
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Xiao-Yu Liu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China.
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9
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Xu T, Gao S, Yang N, Zhao Q, Zhang Y, Li T, Liu Z, Han B. A personalized biomimetic dual-drug delivery system via controlled release of PTH 1-34 and simvastatin for in situ osteoporotic bone regeneration. Front Bioeng Biotechnol 2024; 12:1355019. [PMID: 38357710 PMCID: PMC10865375 DOI: 10.3389/fbioe.2024.1355019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/17/2024] [Indexed: 02/16/2024] Open
Abstract
Patients with osteoporosis often encounter clinical challenges of poor healing after bone transplantation due to their diminished bone formation capacity. The use of bone substitutes containing bioactive factors that increase the number and differentiation of osteoblasts is a strategy to improve poor bone healing. In this study, we developed an in situ dual-drug delivery system containing the bone growth factors PTH1-34 and simvastatin to increase the number and differentiation of osteoblasts for osteoporotic bone regeneration. Our system exhibited ideal physical properties similar to those of natural bone and allowed for customizations in shape through a 3D-printed scaffold and GelMA. The composite system regulated the sustained release of PTH1-34 and simvastatin, and exhibited good biocompatibility. Cell studies revealed that the composite system reduced osteoblast death, and promoted expression of osteoblast differentiation markers. Additionally, by radiographic analysis and histological observation, the dual-drug composite system demonstrated promising bone regeneration outcomes in an osteoporotic skull defect model. In summary, this composite delivery system, comprising dual-drug administration, holds considerable potential for bone repair and may serve as a safe and efficacious therapeutic approach for addressing bone defects in patients with osteoporosis.
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Affiliation(s)
- Tongtong Xu
- Department of Prosthodontics, Hospital of Stomatology, Jilin University, Changchun, China
- Jilin Provincial Key Laboratory of Tooth Development and Bone Remodeling, Jilin University, Changchun, Jilin, China
| | - Shang Gao
- Department of Stomatology, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Nan Yang
- Department of Prosthodontics, Hospital of Stomatology, Jilin University, Changchun, China
| | - Qi Zhao
- Department of Prosthodontics, Hospital of Stomatology, Jilin University, Changchun, China
- Jilin Provincial Key Laboratory of Tooth Development and Bone Remodeling, Jilin University, Changchun, Jilin, China
| | - Yutong Zhang
- School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin, China
| | - Tieshu Li
- School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin, China
| | - Zhihui Liu
- Department of Prosthodontics, Hospital of Stomatology, Jilin University, Changchun, China
| | - Bing Han
- School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin, China
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10
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Li C, Lin X, Lin Q, Lin Y, Lin H. Jiangu granules ameliorate postmenopausal osteoporosis via rectifying bone homeostasis imbalance: A network pharmacology analysis based on multi-omics validation. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 122:155137. [PMID: 37856991 DOI: 10.1016/j.phymed.2023.155137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/23/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Postmenopausal osteoporosis (PMOP) is a series of reactions to bone homeostasis dysregulation mediated by estrogen deficiency in elderly women. Jiangu granules, a traditional Chinese medicine formula, has been proven as an effective treatment approach for PMOP, which still needs more research iin its complex regulatory mechanisms. PURPOSE Our study aimed to identify the putative targets and regulatory mechanisms of Jiangu granules in PMOP treating. METHODS We utilized the NHANES database to compare the clinical information of normal population and PMOP patients. Associated with transcriptomics and proteomic data, we identified the PMOP-related genes, and further studied them with bioinformatic methods including and prognosis model. Network pharmacology was applied for confirming the action targets of Jiangu granules in PMOP. We verified the safety and effectiveness in PMOP treatments of Jiangu granules, and also demonstrated our hypothesis in rats. RESULTS We discovered that the PMOP patients had higher monocytes than the normal women. Moreover, the transcriptomics and proteomic analysis suggested that the dysregulation of PMOP-related genes expression was associated with monocytes, and the Notch pathway were the critical targets representing bone homeostasis imbalance highly involved in the occurrence of PMOP. We also ascertained network pharmacology results further revealing that Jiangu granules might treat PMOP via recovering the bone homeostasis imbalance identified above. In vivo experiments, we confirmed the high efficacy which mainly resulted from function in mitigating the imbalance in bone homeostasis by recovering the normal expression of PMOP-related genes associated with monocytes, Notch, and steroid pathway in the rat models. CONCLUSION Our finding underscored the clinical potential of Jiangu granules in treating PMOP, and enriched the comprehension of the related pathogenic and therapeutic mechanisms.
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Affiliation(s)
- Chaoxiong Li
- Department of Orthopedics, Fuzhou Second Hospital, Fuzhou, China; Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopaedic Trauma(2020Y2014), Fuzhou, China; The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Xiangquan Lin
- Department of Orthopedics, Fuzhou Second Hospital, Fuzhou, China; Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopaedic Trauma(2020Y2014), Fuzhou, China; The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Qin Lin
- Department of Orthopedics, Fuzhou Second Hospital, Fuzhou, China; Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopaedic Trauma(2020Y2014), Fuzhou, China; The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Yanping Lin
- College of Acupuncture and Moxibustion, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Haiming Lin
- College of Integrated Chinese and Western Medicine, Fujian University of Traditional Chinese Medicine, 1st Qiuyang Road, Shangjie Town, Minhou County, Fuzhou, Fujian, China.
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11
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Pasqualini I, Huffman N, Keller SF, McLaughlin JP, Molloy RM, Deren ME, Piuzzi NS. Team Approach: Bone Health Optimization in Orthopaedic Surgery. JBJS Rev 2023; 11:01874474-202312000-00007. [PMID: 38100611 DOI: 10.2106/jbjs.rvw.23.00178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
» Bone health optimization (BHO) has become an increasingly important consideration in orthopaedic surgery because deterioration of bone tissue and low bone density are associated with poor outcomes after orthopaedic surgeries.» Management of patients with compromised bone health requires numerous healthcare professionals including orthopaedic surgeons, primary care physicians, nutritionists, and metabolic bone specialists in endocrinology, rheumatology, or obstetrics and gynecology. Therefore, achieving optimal bone health before orthopaedic surgery necessitates a collaborative and synchronized effort among healthcare professionals.» Patients with poor bone health are often asymptomatic and may present to the orthopaedic surgeon for reasons other than poor bone health. Therefore, it is imperative to recognize risk factors such as old age, female sex, and low body mass index, which predispose to decreased bone density.» Workup of suspected poor bone health entails bone density evaluation. For patients without dual-energy x-ray absorptiometry (DXA) scan results within the past 2 years, perform DXA scan in all women aged 65 years and older, all men aged 70 years and older, and women younger than 65 years or men younger than 70 years with concurrent risk factors for poor bone health. All women and men presenting with a fracture secondary to low-energy trauma should receive DXA scan and bone health workup; for fractures secondary to high-energy trauma, perform DXA scan and further workup in women aged 65 years and older and men aged 70 years and older.» Failure to recognize and treat poor bone health can result in poor surgical outcomes including implant failure, periprosthetic infection, and nonunion after fracture fixation. However, collaborative healthcare teams can create personalized care plans involving nutritional supplements, antiresorptive or anabolic treatment, and weight-bearing exercise programs, resulting in BHO before surgery. Ultimately, this coordinated approach can enhance the success rate of surgical interventions, minimize complications, and improve patients' overall quality of life.
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Affiliation(s)
| | - Nickelas Huffman
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sarah F Keller
- Department of Rheumatology and Immunology, Cleveland Clinic, Cleveland, Ohio
| | | | - Robert M Molloy
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Matthew E Deren
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio
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12
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Poduval M, Vishwanathan K. Definition and Evolution of the Term Osteoporosis. Indian J Orthop 2023; 57:42-44. [PMID: 38107798 PMCID: PMC10721770 DOI: 10.1007/s43465-023-01013-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/28/2023] [Indexed: 12/19/2023]
Abstract
Osteoporosis is a metabolic bone disease in which the loss of bone mineral density causes the bone to become weaker and more susceptible to fracture. In the vulnerable individual, osteoporosis develops as a result of a combination of hereditary and environmental risk factors. The definition of the term osteoporosis as a clinical syndrome has evolved with the improved understanding of the pathogenesis, diagnostic terminology and treatment directions both pharmacological and non-pharmacological, over the past few decades.
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Affiliation(s)
- Murali Poduval
- Lifesciences Engineering, Tata Consultancy Services Ltd, Mumbai, India
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13
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Liu D, Hu Z, Tang Z, Li P, Yuan W, Li F, Chen Q, Min W, Zhao C. Early risk assessment and prediction model for osteoporosis based on traditional Chinese medicine syndromes. Heliyon 2023; 9:e21501. [PMID: 38027808 PMCID: PMC10663826 DOI: 10.1016/j.heliyon.2023.e21501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To evaluate the risk factors of osteoporosis and establish a risk prediction model based on routine clinical information and traditional Chinese medicine (TCM) syndromes. Methods Adults aged 30-82 who lived in 12 grass-roots communities or rural towns in Shanghai, Jilin Province, and Jiangsu Province from December 2019 to January 2022 through a multi-stage sampling method were included in this study. The risk factors and risk prediction of osteoporosis in women and men were explored and established by univariate analysis and multivariate logistic regression model. ROC curve and Hosmer-Lemeshow goodness-of-fit test were used to evaluate the prediction model. Results A total of 3000 subjects including 2243 females (75 %) and 757 males (25 %) were included in this study. The logistic prediction model of osteoporosis in women was Logit (P) = -2.946 + 0.960 (age ≥50 years old) + 0.633 (BMI ≥24 kg/m2) - 0.545 (daily exposure to sunlight >30 min) + 0.519 (no intake of dairy products) + 0.827 (coronary heart disease) + 0.383 (lumbar disc herniation) + 0.654 (no intake of calcium tablets and vitamin D) - 0.509 (insomnia) + 0.580 (flushed face and congested eyes) + 1.194 (thready and rapid pulse) + 1.309 (sunken and slow pulse). The logistic prediction model of osteoporosis in men was Logit (P) = -1.152-0.644 (daily exposure to sunlight >30 min) + 0.975 (no intake of calcium tablets and vitamin D) - 0.488 (insomnia). The area under the ROC curve (AUC) of female and male osteoporosis prediction models was 0.743 and 0.679, respectively. The Hosmer-Lemeshow goodness-of-fit test was >0.5. Conclusions There are some significant differences in risk factors between female and male patients with osteoporosis. The risk of osteoporosis are found to be associated with TCM syndromes, and osteoporosis risk prediction models based on routine clinical information and TCM syndrome is effective.
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Affiliation(s)
- Dan Liu
- Department of Rehabilitation Medicine, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Zhijun Hu
- Department of Rehabilitation Medicine, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Zhanying Tang
- Department of Rehabilitation Medicine, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Pan Li
- Department of Rehabilitation Medicine, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Weina Yuan
- Department of Rehabilitation Medicine, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Fangfang Li
- Department of Rehabilitation Medicine, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Qian Chen
- Department of Rehabilitation Medicine, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Wen Min
- Department of Orthopedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210004, Jiangsu Province, China
| | - Changwei Zhao
- Department of Orthopedics, Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, 130021, Jilin Province, China
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14
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Romano F, Serpico D, Cantelli M, Di Sarno A, Dalia C, Arianna R, Lavorgna M, Colao A, Di Somma C. Osteoporosis and dermatoporosis: a review on the role of vitamin D. Front Endocrinol (Lausanne) 2023; 14:1231580. [PMID: 37693364 PMCID: PMC10484397 DOI: 10.3389/fendo.2023.1231580] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Osteoporosis (OP) and Dermatoporosis (DP) are expressions of the aging process at the skin and bone levels, respectively. Both conditions are associated with increased morbidity for elderly people, and this requires necessary interventions. They share many common risk factors; among these, vitamin D (VD) deficiency appears to have a role. VD is involved in either disease with many mechanisms, among which immunomodulation. VD deficiency has been linked to OP because it inhibits the body's capacity to absorb calcium and maintain optimal bone health. Available evidence suggests that proper vitaminosis D also appears to be vital in preventing skin age-related issues. DP is often seen in elderly individuals, particularly those with long-term sun exposure and a history of chronic sun damage. VD deficiency can be linked to DP, since its involvement in collagen production, epidermal barrier function, inflammation regulation, wound healing, and sun protection. Aim of this review is to summarize the most updated existing evidence on the role of VD in the development of fragility syndromes such as DP and OP and the possible benefits of VD supplementation as a simple and harmful weapon against aging.
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Affiliation(s)
- Fiammetta Romano
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Domenico Serpico
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Mariateresa Cantelli
- Dermatology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Antonella Di Sarno
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Carmine Dalia
- Internal Medicine S. Maria Della Pietà Hospital Nola, Nola, Italy
| | - Rossana Arianna
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Mariarosaria Lavorgna
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Annamaria Colao
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
- UNESCO Chair “Education for Health and Sustainable Development”, University of Naples “Federico II”, Naples, Italy
| | - Carolina Di Somma
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
- UNESCO Chair “Education for Health and Sustainable Development”, University of Naples “Federico II”, Naples, Italy
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