The economic and human costs of osteoporotic fracture

External validation of a deep learning model for predicting bone mineral density on chest radiographs

We developed a new model for predicting bone mineral density on chest radiographs and externally validated it using images captured at facilities other than the development environment. The model performed well and showed potential for clinical use.

PURPOSE

In this study, we performed external validation (EV) of a developed deep learning model for predicting bone mineral density (BMD) of femoral neck on chest radiographs to verify the usefulness of this model in clinical practice.

METHODS

This study included patients who visited any of the collaborating facilities from 2010 to 2020 and underwent chest radiography and dual-energy X-ray absorptiometry (DXA) at the femoral neck in the year before and after their visit. A total of 50,114 chest radiographs were obtained, and BMD was measured using DXA. We developed the model with 47,150 images from 17 facilities and performed EV with 2914 images from three other facilities (EV dataset). We trained the deep learning model via ensemble learning based on chest radiographs, age, and sex to predict BMD using regression. The outcomes were the correlation of the predicted BMD and measured BMD with diagnoses of osteoporosis and osteopenia using the T-score estimated from the predicted BMD.

RESULTS

The mean BMD was 0.64±0.14 g/cm2 in the EV dataset. The BMD predicted by the model averaged 0.61±0.08 g/cm2, with a correlation coefficient of 0.68 (p<0.01) when compared with the BMD measured using DXA. The accuracy, sensitivity, and specificity of the model were 79.0%, 96.6%, and 34.1% for T-score < -1 and 79.7%, 77.1%, and 80.4% for T-score ≤ -2.5, respectively.

CONCLUSION

Our model, which was externally validated using data obtained at facilities other than the development environment, predicted BMD of femoral neck on chest radiographs. The model performed well and showed potential for clinical use.

The effect of Functional Electrical Stimulation-assisted posture-shifting in bone mineral density: case series-pilot study

Study design

A training intervention study using standing dynamic load-shifting Functional Electrical Stimulation (FES) in a group of individuals with complete spinal cord injury (SCI) T2 to T10.

Objectives

Investigate the effect of FES-assisted dynamic load-shifting exercises on bone mineral density (BMD).

Setting

University Lab within the Biomedical Engineering

Methods

Twelve participants with ASIA A SCI were recruited for this study. Three participants completed side-to-side load-shifting FES-assisted exercises for 29 ± 5 weeks, 2× per week for 1 h, and FES knee extension exercises on alternate days 3× per week for 1 h. Volumetric Bone Mineral density (vBMD) at the distal femur and tibia were assessed using peripheral quantitative computed tomography (pQCT) before and after the intervention study.

Results

Participants with acute and subacute SCI showed an absolute increase of f trabecular vBMD (vBMD_TRAB) in the proximal (mean of 26.9%) and distal tibia (mean of 22.35%). Loss of vBMD_TRAB in the distal femur was observed.

Conclusion

Improvements in vBMD_TRAB in the distal tibia were found in acute and subacute SCI participants, and in the proximal tibia of acute participants, when subjected to anti-gravity FES-assisted load-bearing exercises for 29 ± 5 weeks. No vBMD improvement in distal femur or tibial shaft were observed in any of the participants as was expected. However, improvements of vBMD in the proximal and distal tibia were observed in two participants. This study provides evidence of an improvement of vBMD_TRAB, when combining high-intensity exercises with lower intensity exercises 5× per week for 1 h.

Substantial changes in fracture rates in German hospitals in 2018 compared with 2002: an epidemiological study

INTRODUCTION

The aim of this study was to present recent epidemiological data on extremity and axial skeletal fractures in German hospitals and to compare them with older data to detect time trends.

MATERIALS AND METHODS

Inpatient data from the German National Hospital Discharge Registry were used. The absolute number and age-standardized incidence of fractures in 2002 and 2018 were analysed by fracture location according to the International Classification of Disease. Data were analysed according to age group. Male: female ratios (MFRs) and incidence rate ratios (IRRs) were calculated to compare the 2018 and 2002 data.

RESULTS

The absolute number of fractures of the nine analysed locations was 15.2% higher in 2018 than in 2002. By fracture location, the changes were as follows (absolute change + IRR): "neck" (S12): + 172%, IRR = 2.6; "rib(s), sternum, thoracic spine" (S22): + 57%, IRR = 1.3; "lumbar spine and pelvis" (S32): + 66%, IRR = 1.3; "shoulder and upper arm" (S42): + 36%, IRR = 1.2; "forearm" (S52): + 13%, IRR = 1.0; "wrist and hand level" (S62): - 32%, IRR = 0.7; "femur" (S72): + 24%, IRR = 0.9; "lower leg, including ankle" (S82): - 24%, IRR = 0.7; "foot, except ankle" (S92): - 4%, IRR = 0.9. The overall MFR changed from 0.7 in 2002 to 0.6 in 2018. The age group of 45-54 years represented a turning point, males were more often affected than females in the younger age groups, and the opposite trend was observed in the older age groups.

CONCLUSIONS

The increase in the absolute fracture rates was due to increased rates of femur, shoulder, upper arm, forearm, and axial skeletal fractures, with elderly women being the main contributors. Femur fractures were found to be the most common fractures treated in German hospitals.

The Efficacy of Multidisciplinary Team Co-Management Program for Elderly Patients With Intertrochanteric Fractures: A Retrospective Study

Background

Intertrochanteric fractures increased quickly in past decades owing to the increasing number of aging population. Recently, geriatric co-management was rapidly emerging as a favored clinical care model for older patients with hip fractures. The purpose of this study was to assess the efficacy of a multidisciplinary team (MDT) co-management program in elderly patients with intertrochanteric fractures.

Methods

In this retrospective study, patients were divided into MDT group and traditional orthopedic care (TOC) group according to the healthcare model applied. 249 patients were included in the TOC group from January 2014 to December 2016 and 241 patients were included in the MDT group from January 2017 to December 2019. Baseline data, peri-operative data, and postoperative complications were collected and analyzed using SPSS 21.0.

Results

No significant differences were observed between the two groups in terms of patient baseline characteristics. Patients in the MDT group had significantly lower time from admission to surgery and length-of-stay (LOS) compared with those in the TOC group. Furthermore, the proportion of patients receiving surgery within 24 h (61.4 vs. 34.9%, p &lt; 0.001) and 48 h (80.9 vs. 63.5%, p &lt; 0.001) after admission to the ward was significantly higher in the MDT group compared with those in the TOC group. In addition, patients in the MDT group had significantly lower proportion of postoperative complications (25.3 vs. 44.2%, p &lt; 0.001), deep vein thrombosis (7.9 vs. 12.9%, p = 0.049), pneumonia (3.8 vs. 8.0%, p = 0.045) and delirium (4.1 vs. 9.2%, p = 0.025) compared with those in the TOC group. However, no significant changes were found for in-hospital and 30-day mortality.

Conclusion

The MDT co-management could significantly shorten the time from admission to surgery, LOS, and reduce the postoperative complications for elderly patients with intertrochanteric fractures. Further research was needed to evaluate the impact of this model on patient health outcomes.

Prevalence and Risk Factors for Osteopathy in Chronic Pancreatitis

BACKGROUND AND AIMS

The high incidence of osteopathy among patients with chronic pancreatitis (CP) has garnered increased attention over recent years. The aims of this study were to assess the prevalence and risk factors for osteopathy in Chinese patients with CP.

METHODS

This was a cross-sectional study of CP patients from a large center in China; patients were recruited between 31 January 2017 and 31 January 2018. Bone density and laboratory tests, including bone-related biochemical, inflammatory, and hormone parameters, were assessed prospectively. Differences between patients with and without osteopathy were analyzed. Logistic regression analysis was used to investigate associations between variables.

RESULTS

In total, 104 CP patients were enrolled in this study (68.3% idiopathic and 31.7% alcoholic). According to the M-ANNHEIM classification, 87.5% of the patients were at an early stage (0-II). Osteopenia was diagnosed in 30.8% of patients and osteoporosis in 5.8%; thus, a total of 36.5% of patients presented with osteopathy. In multivariate analysis, the independent risk factors for osteopathy in CP patients were age (OR = 1.04; 95% CI = 1.00-1.08; P = 0.030), BMI (OR = 0.72; 95% CI = 0.58-0.89; P = 0.003), and PTH (OR = 0.96; 95% CI = 0.93-1.00; P = 0.022).

CONCLUSIONS

This study is the first to report the prevalence of osteopathy in Chinese patients with CP. It found that age and low BMI are significant risk factors for osteopathy. Low PTH (but within the normal range) showed a weak association with osteopathy, which warrants further exploration.

Efficacy of Pulsed Electromagnetic Fields on Experimental Osteopenia in Rodents: A Systematic Review

Osteoporosis leads to increased bone fragility and risk of fractures. Different strategies have been employed to reduce bone loss, including the use of a pulsed electromagnetic field (PEMF). Although many experimental studies have demonstrated the effect of PEMF on reduction of bone loss, the outcomes studied are varied and insufficient, and the quality of evidence is unknown. Therefore, the aim of this review was to assess the preclinical evidence on the effect of PEMF on bone loss. The existing challenges were also evaluated, and suggestions were provided to strengthen the quality of evidence in future studies. All original articles concerning the effect of PEMF on osteoporosis in animal models were included. Twenty-four studies met the inclusion criteria, 23 of which suggested that PEMF was effective in reducing bone loss, while one study failed to demonstrate any benefit. Risk of bias analysis suggested that information on key measures to reduce bias was frequently not reported. Animal models for osteoporosis, PEMF intervention regimens, outcomes, and specific bone detection sites seemed to influence the efficacy of PEMF in osteoporosis. Our results indicate the potential benefits of PEMF selection in animal models of osteoporosis. However, due to the heterogeneity of the parameters and the quality of the included literature, comprehensive studies using standardized protocols are warranted to confirm the results. © 2021 Bioelectromagnetics Society.

Fracture risk among treatment-naïve postmenopausal women with osteopenia in Greece: results from the "ACROSS" study

Use of the FRAX (Fracture Risk Assessment Tool) tool to assess fracture risk is the most common practice worldwide. Our findings suggest that in treatment-naïve women with osteopenia treatment would be cost-effective for approximately one-third of the study population and nearly half of the subjects over 75 years, according to the Greek-specific FRAX-based thresholds.

INTRODUCTION

When evaluating a patient with low bone mineral density (BMD), fracture risk estimation is of paramount importance. Fracture risk assessment using the FRAX tool is the most common and most studied practice worldwide.

PATIENTS-METHODS

The primary aim of the "ACROSS" study was to record the 10-year probability of major osteoporotic fractures and hip fractures, using the Greek version of the FRAX tool, in a rather representative population of 230 postmenopausal treatment-naïve women with osteopenia. Secondary aims of the study were to identify (1) the risk for fractures according to age and the years from menopause, (2) the proportion of patients qualifying for treatment according to the Greek cost-effective FRAX thresholds, and (3) the perception of both the patient and the treating physician regarding the estimated fracture risk.

RESULTS

The mean 10-year risk was 10.7% ± 6.6 for major osteoporotic fractures and 3.4% ± 4.2 for hip fractures. For women up to 75 years of age, the 10-year risk for major osteoporotic and hip fractures was 8.8% and 2.1%, respectively, while for women over 75 years, the risk was 15.2% and 6.6%, respectively. Patients generally believed that they had low fracture risk independently of age, while the physicians considered that the risk increases with advancing age.

CONCLUSIONS

According to the Greek-specific FRAX-based thresholds, the administration of osteoporosis treatment would be cost-effective for approximately one-third of the study population and nearly half of the subjects over 75 years. Patients are not fully aware of their fracture risk.

Timeline of functional recovery after hip fracture in seniors aged 65 and older: a prospective observational analysis

We investigated the timeline of functional recovery after hip fracture over 12 months in adults age ≥ 65 years using objective lower extremity function tests and subjective physical functioning. Objective functional recovery was largely complete in the first 6 months, whereas subjective recovery improved up to 9 months after hip fracture.

INTRODUCTION

Hip fractures are a major cause of loss of function among seniors. We assessed the timeline of objective and subjective functional recovery after hip fracture.

METHODS

We conducted a prospective observational secondary analysis of a 1-year clinical trial on vitamin D and home exercise treatment and complications after hip fracture among 173 patients age ≥ 65 years (mean age 84 years; 79.2% women; 77.4% community-dwelling) conducted from January 2005 through December 2007. Lower extremity function (Timed Up and Go test (TUG), knee extensor and flexor strength) and grip strength was assessed at baseline and at 6 and 12 months follow-up. Subjective physical functioning was assessed using the SF-36 questionnaire also at 3 and 9 months follow-up. Multivariable-adjusted repeated-measures models were used to assess the timeline of functional recovery in the total population and in subgroups of patients.

RESULTS

Lower extremity function including TUG (- 61.1%), knee extensor (+ 17.6%), and knee flexor (+ 11.6%) strength improved significantly in the first 6 months (P < 0.001). However, between 6 and 12 months, there was no further significant improvement for any of the functional tests. Grip strength decreased from baseline to 6 months (- 7.9%; P < 0.001) and from 6 to 12 months (- 10.8%; P < 0.001). Subjective physical functioning improved from 3 to 9 months (+ 15.2%, P < 0.001), but no longer thereafter.

CONCLUSIONS

Functional recovery after hip fracture may be largely complete in the first 6 months for objective functional tests, whereas may extend up to 9 months for subjective recovery, with oldest-old, female, institutionalized, and cognitively impaired patients recovering most poorly.

CLINICAL TRIALS REGISTRY (ORIGINAL TRIAL)

NCT00133640.

Proton Pump Inhibitor Use, H2-Receptor Antagonist Use, and Risk of Incident Clinical Vertebral Fracture in Women

The few prospective studies examining the relation between proton pump inhibitor (PPI) use and risk of vertebral fracture (VF) suggest a higher risk, but the magnitude of the association has been inconsistent. Moreover, no prospective studies have examined the association between substantially longer duration of PPI use and VF risk. Our objective was to determine the association between PPI use, H₂RA use, and incident clinical VF in women. We conducted a prospective study in 55,545 women participating in the Nurses' Health Study. PPI and H₂RA use was assessed by questionnaire every 4 years. Self-reports of VF were confirmed by medical record. Our analysis included 547 incident VF cases (2002-2014). The multivariate adjusted relative risk (MVRR) of VF for women taking PPIs was 1.29 (95% CI 1.04-1.59) compared with non-users. Longer duration of PPI use was associated with higher VF risk (MVRR 1.16 [0.90-1.49] for < 4 years; 1.27 [0.93-1.73] for 4-7.9 years; 1.64 [1.02-2.64] for ≥ 8 years; p_trend = 0.01). The MVRR of VF for women taking H₂RAs was 1.22 (0.90-1.67) compared with non-users. Longer duration of H₂RA use was not associated with VF risk (MVRR 1.16 [0.88-1.53] for < 4 years; 0.98 [0.60-1.59] for ≥ 4 years; p_trend = 0.72). PPI use is independently associated with a modestly higher risk of VF and the risk increases with longer duration of use. There was no statistically significant association between H₂RA use and VF risk. Our findings add to the growing evidence suggesting caution with PPI use, particularly with longer duration of use.

The Economic Burden of Stroke Based on South Korea's National Health Insurance Claims Database

Background: This study was conducted to determine the scale and the nature of the economic burden caused by strokes and to use the results as an evidential source for determining the allocation of South Korea stroke cases in 2015.

Methods: For research subjects, the study analyzed demographic characteristics and economic burden based on data from national health insurance (NHI) claims for inpatient and outpatient cases of ischemic stroke and hemorrhagic stroke in 2015 through the Health Insurance Review and Assessment Service (HIRA) and statistical data regarding cause of death from the Korea National Statistical Office (KNSO). This study, in order to estimate economic burden due to stroke, deduced the direct and indirect costs of illness caused by stroke, using cost-of-illness (COI) methods. The economic burden is divided into direct and indirect costs, and indirect cost is estimated by summing lost productivity measured in opportunity cost lost by medical disposition due to a specific disease and lost productivity due to premature death.

Results: The total economic burden in Korea due to stroke was US$6.855 billion, that due to ischemic stroke was US$3.658 billion, and that due to hemorrhagic stroke was US$3.197 billion. The average economic burden per stroke case was about US$7247.

Conclusion: The results of estimating the annual economic burden in all of Korea due to stroke will be used as an evidential source for preparing medical insurance policies, priorities, and plans for arranging medical resources for stroke as well as for determining effective prevention of the disease and related priorities in national health care policies.

Bone mineral density in vocational and professional ballet dancers

According to existing literature, bone health in ballet dancers is controversial. We have verified that, compared to controls, young female and male vocational ballet dancers have lower bone mineral density (BMD) at both impact and non-impact sites, whereas female professional ballet dancers have lower BMD only at non-impact sites.

INTRODUCTION

The aims of this study were to (a) assess bone mineral density (BMD) in vocational (VBD) and professional (PBD) ballet dancers and (b) investigate its association with body mass (BM), fat mass (FM), lean mass (LM), maturation and menarche.

METHODS

The total of 152 VBD (13 ± 2.3 years; 112 girls, 40 boys) and 96 controls (14 ± 2.1 years; 56 girls, 40 boys) and 184 PBD (28 ± 8.5 years; 129 females, 55 males) and 160 controls (27 ± 9.5 years; 110 female, 50 males) were assessed at the lumbar spine (LS), femoral neck (FN), forearm and total body by dual-energy X-ray absorptiometry. Maturation and menarche were assessed via questionnaires.

RESULTS

VBD revealed lower unadjusted BMD at all anatomical sites compared to controls (p < 0.001); following adjustments for Tanner stage and gynaecological age, female VBD showed similar BMD values at impact sites. However, no factors were found to explain the lower adjusted BMD values in VBD (female and male) at the forearm (non-impact site), nor for the lower adjusted BMD values in male VBD at the FN. Compared to controls, female PBD showed higher unadjusted and adjusted BMD for potential associated factors at the FN (impact site) (p < 0.001) and lower adjusted at the forearm (p < 0.001). Male PBD did not reveal lower BMD than controls at any site.

CONCLUSIONS

Both females and males VBD have lower BMD at impact and non-impact sites compared to control, whereas this is only the case at non-impact site in female PBD. Maturation seems to explain the lower BMD at impact sites in female VBD.

Effect of periodontitis on the development of osteoporosis: results from a nationwide population-based cohort study (2003-2013)

Background

The prevalence of osteoporosis associated with the aging process is anticipated to increase along with the rising aging population. Periodontitis that the most common chronic infections of humankind is considered the risk factor for osteoporosis. The aim of this study was to identify the association between osteoporosis and periodontitis using a population-based cohort.

Methods

The case group was defined as patients diagnosed with periodontitis and treated with subgingival curettage, root conditioning, periodontal flap operation, bone grafting for alveolar bone defects, and guided tissue regeneration. Case and control groups matched for gender, age, household income, type of social security, disability, and residential area were generated. A Cox proportional hazard model was constructed to examine the difference in the development of osteoporosis between the case and control groups. The final sample included 13,464 participants.

Results

The incidence of osteoporosis was 1.1% in males and 15.8% in females during a 10-year period. The risk factors for osteoporosis in males were increasing age and Charlson Comorbidity Index score. Periodontitis was not associated with the development of osteoporosis in males. The risk factors for osteoporosis in females were increasing age, body mass index, Charlson Comorbidity Index score, diabetes, and periodontitis. Women with periodontitis were more likely to also develop osteoporosis (HR: 1.22, 95% CI: 1.01–1.48).

Conclusions

Periodontitis has an effect on the development of osteoporosis in females. Managing good teeth is required for the prevention and delay of osteoporosis. This includes dental examinations, regular cleanings and gum treatment.

Trabecular Microstructure and Damage Affect Cement Leakage From the Basivertebral Foramen During Vertebral Augmentation

STUDY DESIGN

A prospective study on cadaver specimens.

OBJECTIVE

To explore why cement leakage from basivertebral foramen (BF) easily occurs during vertebral augmentation procedures.

SUMMARY OF BACKGROUND DATA

Type B (through BF, basivertebral foramen) cement leakage is the most common type after vertebral augmentation, but the mechanism of this is still controversial. The contribution of vertebral trabecular bone orientation and trabecular damage during compression fracture to cement leakage is still unknown.

METHODS

In this study, 12 fresh-frozen human lumbar spines (T12-L5) were collected and divided into 24 three-segment units. Mechanical testing was performed to simulate a compression fracture. MicroCT were performed on all segments before and after mechanical testing, and trabecular microstructure of the superior, middle (containing BF), and inferior 1/3 of each vertebral body was analyzed. The diameter variation of intertrabecular space before and after compression fracture was used to quantify trabecular injury. After mechanical testing, vertebral augmentation, and imaging-based diagnosis were used to evaluate cement leakage.

RESULTS

Trabecular bone microstructural parameters in middle region (containing BF) were lower than those of the superior or inferior regions (P < 0.01). After compressive failure, 3D-reconstruction of the vertebral body by MicroCT demonstrated that intertrabecular distance in the middle region was markedly increased. Type B cement leakage was the most common type after vertebral augmentation, as found previously in Wang et al. (Spine J 2014;14: 1551-1558).

CONCLUSION

The presence of the BF and the relative sparsity of trabecular bone make the middle region of the vertebral body the mechanically weakest region. Trabecular bone in middle region suffered the most severe damage during compressive failure of the vertebral body, which resulted in the greatest intervertebral spacing, and subsequently the highest percentage of type B cement leakage. These data suggest specific mechanisms by which cement may leak from the BF, and the contribution of trabecular microstructure and trabecular injury.

LEVEL OF EVIDENCE

4.

Diuretic Use and Risk of Vertebral Fracture in Women

BACKGROUND

Vertebral fracture is the most common type of osteoporotic fracture. While thiazide diuretics, which are commonly prescribed for the treatment of hypertension, decrease calciuria, they may also induce hyponatremia, which has been associated with increased vertebral fracture risk. Loop diuretics increase calciuria, which would reduce bone mineral density and increase vertebral fracture risk, but they rarely cause hyponatremia. Recent studies on diuretics and fractures did not include or specifically examine vertebral fracture. The few studies of diuretics and vertebral fracture have been limited by cases defined by self-report or administrative data, relatively small number of cases, study design that was not prospective, and lack of long-term follow-up with updated information on diuretic use.

METHODS

We conducted a prospective cohort study of thiazide diuretic use, loop diuretic use, and risk of incident clinical vertebral fracture in 55,780 women, 55-82 years of age, participating in the Nurses' Health Study, without a prior history of any fracture. Diuretic use was assessed by questionnaire every 4 years. Self-reported vertebral fracture was confirmed by medical record review. Cox proportional-hazards models were used to simultaneously adjust for potential confounders.

RESULTS

Our analysis included 420 incident vertebral fracture cases documented between 2002 and 2012. The multivariate-adjusted relative risk of clinical vertebral fracture for women taking thiazides compared with women not taking thiazides was 1.47 (95% confidence interval, 1.18-1.85). The multivariate adjusted relative risk of vertebral fracture for women taking loop diuretics compared with women not taking loop diuretics was 1.59 (95% confidence interval, 1.12-2.25).

CONCLUSION

Thiazide diuretics and loop diuretics are each independently associated with increased risk of vertebral fracture in women.

Patient variables and referral paradigms associated with osteoporosis screening and treatment in neurosurgical patients undergoing kyphoplasty

OBJECT Vertebral fractures are the most common osteoporotic fracture. Bone density testing and medical treatment with bisphosphonates or parathormone are recommended for all patients with an osteoporotic fracture diagnosis. Inadequate testing and treatment of patients presenting with low-impact fractures have been reported in various specialties. Similar data are not available from academic neurosurgery groups. The authors assessed compliance with treatment and testing of osteoporosis in patients with vertebral compression fractures evaluated by the authors' academic neurosurgery service, and patient variable and health-systems factors associated with improved compliance. METHODS Data for patients who underwent percutaneous kyphoplasty for compression fractures was retrospectively collected. Diagnostic and medical interventions were tabulated. Pre-, intra-, and posthospital factors that had been theorized to affect the compliance of patients with osteoporosis-related therapies were tabulated and statistically analyzed. RESULTS Less than 50% of patients with kyphoplasty received such therapies. Age was not found to correlate with other variables. Referral from a specialist rather than a primary care physician was associated with a higher rate of bone density screening, as well as vitamin D and calcium therapy, but not bisphosphonate/parathormone therapy. Patients who underwent preoperative evaluation by their primary care physician were significantly more likely to receive bisphosphonates compared with those only evaluated by a hospitalist. Patients with unprovoked fractures were more likely to undergo multiple surgeries compared with those with minor trauma. CONCLUSIONS These results suggest poor compliance with current standard of care for medical therapies in patients with osteoporotic compression fractures undergoing kyphoplasty under the care of an academic neurosurgery service.

Anti-Osteoporotic Therapy After Fragility Fracture Lowers Rate of Subsequent Fracture: Analysis of a Large Population Sample

BACKGROUND

This investigation assessed the effectiveness of initiating anti-osteoporotic therapy after a fragility fracture in preventing subsequent fractures.

METHODS

The Truven Health MarketScan databases, which contain de-identified, integrated, person-specific claim data, were queried from 2003 to 2012. The study population included individuals fifty years of age or older who sustained a fragility fracture, defined as any fracture of the wrist, proximal part of the humerus, hip, or vertebra, and had three years of continuous enrollment following fracture. Patients were stratified into either an anti-osteoporotic therapy group or a no-treatment group. Subsequent fracture was defined as a fragility fracture occurring more than ninety days following the index fracture. Subjects were followed for three years. Unadjusted and age and sex-adjusted odds ratios for subsequent fracture were calculated for both groups.

RESULTS

This investigation included 31,069 subjects, of whom 10.6% were treated with anti-osteoporotic therapy following the index fracture. The anti-osteoporotic therapy group was older and had a greater proportion of female patients compared with the no-treatment group. The three-year subsequent fracture rates were 7.5% in the anti-osteoporotic therapy group and 9.7% in the no-treatment group. Unadjusted odds ratios for subsequent fracture showed that the anti-osteoporotic therapy group experienced a risk reduction of 33% after an index wrist fracture, 48% after an index proximal humeral fracture, 28% after an index hip fracture, 20% after an index vertebral fracture, and 25% after all fractures combined. Age and sex-adjusted odds ratios showed that the anti-osteoporotic therapy group experienced a reduction in risk of 50% after an index wrist fracture, 52% after an index proximal humeral fracture, 34% after an index hip fracture, 43% after an index vertebral fracture, and 40% after all fractures combined. The number needed to treat to prevent a subsequent fragility fracture was twenty-eight after an index wrist fracture, twenty after an index proximal humeral fracture, twenty-six after an index hip fracture, twenty-five after an index vertebral fracture, and twenty-seven after all fractures combined.

CONCLUSIONS

Treatment with anti-osteoporotic therapy after a fragility fracture leads to a 40% decrease in the three-year risk of subsequent fracture, when adjusted for age and sex. Initiation of anti-osteoporotic therapy following a fragility fracture can prevent a subsequent fracture over the following three years in approximately one of every twenty-seven patients treated.

Cortical bone histomorphometry in male femoral neck: the investigation of age-association and regional differences

Low bone volume and changes in bone quality or microarchitecture may predispose individuals to fragility fractures. As the dominant component of the human skeleton, cortical bone plays a key role in protecting bones from fracture. However, histological investigations of the underlying structural changes, which might predispose to fracture, have been largely limited to the cancellous bone. The aim of this study was to investigate the age-association and regional differences of histomorphometric properties in the femoral neck cortical bone. Undecalcified histological sections of the femoral neck (n = 20, aged 18-82 years, males) were cut (15 μm) and stained using modified Masson-Goldner stain. Complete femoral neck images were scanned, and cortical bone boundaries were defined using our previously established method. Cortical bone histomorphometry was performed with low (×50) and high magnification (×100). Most parameters related to cortical width (Mean Ct.Wi, Inferior Ct.Wi, Superior Ct.Wi) were negatively associated with age both before and after adjustment for height. The inferior cortex was the thickest (P < 0.001) and the superior cortex was the thinnest (P < 0.008) of all cortical regions. Both osteonal size and pores area were negatively associated with age. Osteonal area and number were higher in the antero-inferior area (P < 0.002) and infero-posterior area (P = 0.002) compared to the postero-superior area. The Haversian canal area was higher in the infero-posterior area compared to the postero-superior area (P = 0.002). Moreover, porosity was higher in the antero-superior area (P < 0.002), supero-anterior area (P < 0.002) and supero-posterior area (P < 0.002) compared to the infero-anterior area. Eroded endocortical perimeter (E.Pm/Ec.Pm) correlated positively with superior cortical width. This study describes the changes in cortical bone during ageing in healthy males. Further studies are needed to investigate whether these changes explain the increased susceptibility to femoral neck fractures.

Incidence of and factors for self-reported fragility fractures among middle-aged and elderly women in rural Korea: an 11-year follow-up study

Objectives:

This community-based cohort study was performed to investigate the incidence of and factors related to self-reported fragility fractures among middle-aged and elderly women living in rural Korea.

Methods:

The osteoporosis cohort recruited 430 women 40 to 69 years old in 1999, and 396 of these women were followed over 11 years. In 1999, questionnaires from all participants assessed general characteristics, medical history, lifestyle, menstrual and reproductive characteristics, and bone mineral density. In 2010, self-reported fractures and the date, site, and cause of these fractures were recorded. Cox proportional hazards models were used to calculate hazard ratios (HRs).

Results:

Seventy-six participants among 3949.7 person-years experienced fragility fractures during the 11-year follow-up. The incidence of fragility fractures was 1924.2 per 100 000 person-years (95% confidence interval [CI], 1491.6 to 2356.8). In the multivariate model, low body mass index (HR, 2.66; 95% CI, 1.13 to 6.24), a parental history of osteoporosis (HR, 2.03; 95% CI, 1.18 to 3.49), and postmenopausal status (HR, 3.50; 95% CI, 1.05 to 11.67) were significantly related to fragility fracture.

Conclusions:

Fracture prevention programs are needed among postmenopausal, rural, Korean women with a low body mass index and parental history of osteoporosis Korea.

Design, synthesis, and osteogenic activity of daidzein analogs on human mesenchymal stem cells

Osteoporosis is caused by an overstimulation of osteoclast activity and the destruction of the bone extracellular matrix. Without the normal architecture, osteoblast cells are unable to rebuild phenotypically normal bone. Hormone replacement therapy with estrogen has been effective in increasing osteoblast activity but also has resulted in the increased incidence of breast and uterine cancer. In this study we designed and synthesized a series of daidzein analogs to investigate their osteogenic induction potentials. Human bone marrow derived mesenchymal stem cells (MSCs) from three different donors were treated with daidzein analogs and demonstrated enhanced osteogenesis when compared to daidzein treatment. The enhanced osteogenic potential of these daidzein analogs resulted in increased osterix (Sp7), alkaline phosphatase (ALP), osteopontin (OPN), and insulin-like growth factor 1 (IGF-1), which are osteogenic transcription factors that regulate the maturation of osteogenic progenitor cells into mature osteoblast cells.

Economic viability of geriatric hip fracture centers

Management of geriatric hip fractures in a protocol-driven center can improve outcomes and reduce costs. Nonetheless, this approach has not spread as broadly as the effectiveness data would imply. One possible explanation is that operating such a center is not perceived as financially worthwhile. To assess the economic viability of dedicated hip fracture centers, the authors built a financial model to estimate profit as a function of costs, reimbursement, and patient volume in 3 settings: an average US hip fracture program, a highly efficient center, and an academic hospital without a specific hip fracture program. Results were tested with sensitivity analysis. A local market analysis was conducted to assess the feasibility of supporting profitable hip fracture centers. The results demonstrate that hip fracture treatment only becomes profitable when the annual caseload exceeds approximately 72, assuming costs characteristic of a typical US hip fracture program. The threshold of profitability is 49 cases per year for high-efficiency hip fracture centers and 151 for the urban academic hospital under review. The largest determinant of profit is reimbursement, followed by costs and volume. In the authors’ home market, 168 hospitals offer hip fracture care, yet 85% fall below the 72-case threshold. Hip fracture centers can be highly profitable through low costs and, especially, high revenues. However, most hospitals likely lose money by offering hip fracture care due to inadequate volume. Thus, both large and small facilities would benefit financially from the consolidation of hip fracture care at dedicated hip fracture centers. Typical US cities have adequate volume to support several such centers.

In vivo stimulation of bone formation by aluminum and oxygen plasma surface-modified magnesium implants

A newly developed magnesium implant is used to stimulate bone formation in vivo. The magnesium implant after undergoing dual aluminum and oxygen plasma implantation is able to suppress rapid corrosion, leaching of magnesium ions, as well as hydrogen gas release from the biodegradable alloy in simulated body fluid (SBF). No released aluminum is detected from the SBF extract and enhanced corrosion resistance properties are confirmed by electrochemical tests. In vitro studies reveal enhanced growth of GFP mouse osteoblasts on the aluminum oxide coated sample, but not on the untreated sample. In addition to that a small amount (50 ppm) of magnesium ions can enhance osteogenic differentiation as reported previously, our present data show a low concentration of hydrogen can give rise to the same effect. To compare the bone volume change between the plasma-treated magnesium implant and untreated control, micro-computed tomography is performed and the plasma-treated implant is found to induce significant new bone formation adjacent to the implant from day 1 until the end of the animal study. On the contrary, bone loss is observed during the first week post-operation from the untreated magnesium sample. Owing to the protection offered by the Al2O3 layer, the plasma-treated implant degrades more slowly and the small amount of released magnesium ions stimulate new bone formation locally as revealed by histological analyses. Scanning electron microscopy discloses that the Al2O3 layer at the bone-implant interface is still present two months after implantation. In addition, no inflammation or tissue necrosis is observed from both treated and untreated implants. These promising results suggest that the plasma-treated magnesium implant can stimulate bone formation in vivo in a minimal invasive way and without causing post-operative complications.

Low-modulus Mg/PCL hybrid bone substitute for osteoporotic fracture fixation

In this paper, we describe a new biodegradable composite composed of polycaprolactone and magnesium. Incorporation of magnesium micro-particles into the polycaprolactone matrix yields mechanical properties close to those of human cancellous bone, and in vitro studies indicate that the silane-coated Mg/PCL composites have excellent cytocompatibility and osteoblastic differentiation properties. The bioactivity of the composites is manifested by the formation of calcium and phosphate after immersion in simulated body fluids. The bulk mechanical properties can be maintained for 2 months before obvious degradation takes place. The in vivo animal study reveals a larger amount of new bone formation on the silane-coated Mg/PCL composites compared to conventional PMMA and pure polycaprolactone and our results suggest potential clinical applications of the sliane-coated Mg/PCL composites.

BMD changes and predictors of increased bone loss in postmenopausal women after a 5-year course of alendronate

Management of women discontinuing bisphosphonates after 3 to 5 years of treatment is controversial. Little is known about how much bone mineral density (BMD) is lost after discontinuation or whether there are risk factors for greater rates of bone loss post-discontinuation. We report patterns of change in BMD and prediction models for the changes in BMD in postmenopausal women during a 5-year treatment-free period after alendronate (ALN) therapy. We studied 406 women enrolled in the Fracture Intervention Trial (FIT) who had taken ALN for a mean of 5 years and were then enrolled in the placebo arm of the FIT Long-Term Extension (FLEX) trial for an additional 5 years, describing 5-year percent changes in total hip, femoral neck, and lumbar spine BMD over the treatment-free period. Prediction models of 5-year percent changes in BMD considered all linear combinations of candidate risk factors for bone loss such as BMD at the start of the treatment-free period, the change in BMD on ALN, age, and fracture history. Serum for three markers of bone turnover was available in 76 women, and these bone turnover markers were included as candidate predictors for these 76 women. Mean 5-year BMD changes were -3.6% at the total hip, -1.7% at the femoral neck, and 1.3% at the lumbar spine. Five-year BMD losses of >5% were experienced by 29% of subjects at the total hip, 11% of subjects at the femoral neck, and 1% of subjects at the lumbar spine. Several risk factors such as age and BMI were associated with greater bone loss, but no models based on these risk factors predicted bone loss rates. Although about one-third of women who discontinued ALN after 5 years experienced >5% bone loss at the total hip, predicting which women will lose at a higher rate was not possible.

Comparison of an organized geriatric fracture program to United States government data

OBJECTIVE

This study describes the financial impact of an organized hip fracture program for elderly patients age 65 years and older.

METHODS

This is a retrospective study of 797 fractures in 776 consecutive patients over a 50-month period (May 2005 to July 2009) treated in an organized hip fracture program for the elderly identified from a quality management database. Financial, demographic, and quality-of-care data were collected. The length of hospital stay, in-hospital complications, and Charlson comorbidity scores were collected from patient records, and all data were evaluated using standard statistical methods.

SETTING

261-bed community-based, university-affiliated teaching hospital in an urban setting with a catchment area of approximately 1 million persons. This is a level 3 trauma center.

RESULTS

The average total net revenue per hip fracture was $12 159, with an average total cost to hospital of $8264. Physicians' fees consisted of fees collected by surgeons, anesthesiologists, medical specialty consultants, and consulting geriatricians and averaged $2024 per case. Thus, the average hospital charge to payers was $15 188. Compared to Agency for Healthcare Research and Quality average inpatient hospital costs in 2005 of $33 693, a savings of more than $18 000 was realized per patient. The average length of stay was 4.6 days, markedly less than the national average of 6.2 days.

CONCLUSIONS

This organized geriatric fracture care model with geriatrics comanagement resulted in significant cost savings over a 50-month period, with associated increased quality. With an estimated 330 000 hip fractures annually in the United States, a large cost savings could potentially be realized if this model were more widely applied.

Association between hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes

AIMS

This retrospective observational study examined the association between International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-coded outpatient hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes.

METHODS

Data were derived from healthcare claims for individuals with employer-sponsored Medicare supplemental insurance. The study period consisted of two consecutive 1-year periods; the baseline period (1 April 2008 to 31 March 2009) and the evaluation period (1 April 2009 to 31 March 2010). Patients selected for study were at least 65 years of age with evidence of type 2 diabetes during the baseline period, as identified using a Healthcare Effectiveness Data and Information Set algorithm or by at least two prescription claims for oral antidiabetic drugs. The baseline period was used to collect information on the patients' demographics and clinical characteristics. The evaluation period was used to identify the presence of hypoglycaemic events and fall-related fractures. Logistic regression was employed to examine the association between hypoglycaemic events and fall-related fractures occurring during the evaluation period, adjusting for patients' demographics and clinical characteristics.

RESULTS

Of 361 210 included patients, 16 936 had hypoglycaemic events during the evaluation period. Patients with hypoglycaemic events had 70% higher regression-adjusted odds (hypoglycaemic events odds ratio = 1.70; 95% confidence interval = 1.58-1.83) of fall-related fractures than patients without hypoglycaemic events. Multiple sensitivity analyses also yielded results suggesting increased odds of fall-related fractures in patients with hypoglycaemic events.

CONCLUSIONS

ICD-9-CM-coded outpatient hypoglycaemic events were independently associated with an increased risk of fall-related fractures. Further studies of the relationship between hypoglycaemia and the risk of fall-related fractures are warranted.

Is anemia at admission related to short-term outcomes of elderly hip fracture patients?

Hip fracture in elderly people is associated with high morbidity and mortality. Therefore, it is important to identify risk factors that potentially influence outcomes after hip surgery. The main purpose of this study was to evaluate the relationship of anemia at admission and short-term outcomes after hip fracture. We studied 343 community-dwelling patients who underwent surgery for hip fracture from March 2009 to March 2010. Functional mobility at discharge, postoperative complications, hospital length of stay and in-hospital mortality were analyzed in respect to presence and severity of anemia at admission. Anemia (defined as hemoglobin levels < 13.0 g/dl for men and < 12.0g/dl for women) was present in 185 (53.9%) patients, of whom 54 (29.2%) were severely anemic (defined as hemoglobin level 10.0g/dl or below). In multivariate analysis anemia was associated with age, gender (female), type of fracture (intertrochanteric) and American Society of Anesthesiologists (ASA) classification (3 or 4), while severity of anemia was associated with recovery of ambulatory ability at discharge. There was no difference in the incidence of postoperative complication, in-hospital mortality and length of hospital stay between the groups at discharge. Overall anemia at admission is an indicator of poor general health status. Ambulatory recovery in hip fracture patients is independently related to severity of anemia at admission.

Exercise prescription after fragility fracture in older adults: a scoping review

The purpose of this study is to identify and chart research literature on safety, efficacy, or effectiveness of exercise prescription following fracture in older adults. We conducted a systematic, research-user-informed, scoping review. The population of interest was adults aged ≥45 years with any fracture. "Exercise prescription" included post-fracture therapeutic exercise, physical activity, or rehabilitation interventions. Eligible designs included knowledge synthesis studies, primary interventional studies, and observational studies. Trained reviewers independently evaluated citations for inclusion. A total of 9,415 citations were reviewed with 134 citations (119 unique studies) identified: 13 knowledge syntheses, 95 randomized or controlled clinical trials, and 11 "other" designs, representing 74 articles on lower extremity fractures, 34 on upper extremity, eight on vertebral, and three on mixed body region fractures. Exercise prescription characteristics were often missing or poorly described. Six general categories emerged describing exercise prescription characteristics: timing post-fracture, person prescribing, program design, functional focus, exercise script parameters, and co-interventions. Upper extremity and ankle fracture studies focused on fracture healing or structural impairment outcomes, whereas hip fracture studies focused more on activity limitation outcomes. The variety of different outcome measures used made pooling or comparison of outcomes difficult. There was insufficient information to identify evidence-informed parameters for safe and effective exercise prescription for older adults following fracture. Key gaps in the literature include limited numbers of studies on exercise prescription following vertebral fracture, poor delineation of effectiveness of different strategies for early post-fracture mobilization following upper extremity fracture, and inconsistent details of exercise prescription characteristics after lower extremity fracture.

The effects of excipients and particle engineering on the biophysical stability and aerosol performance of parathyroid hormone (1-34) prepared as a dry powder for inhalation

Pulmonary delivery of therapeutic peptides and proteins has many advantages including high relative bioavailability, rapid systemic absorption and onset of action and a non-invasive mode of administration which improves patient compliance. In this study, we investigated the effect of spray-drying (SD) and spray freeze-drying processes on the stability and aerosol performance of parathyroid hormone (PTH) (1-34) microparticles. In this study, the stabilisation effect of trehalose (a non-reducing sugar) and Brij 97 (a non-ionic surfactant) on spray-dried PTH particles was assessed using analytical techniques including circular dichroism (CD), fluorescence spectroscopy, modulated differential scanning calorimetry and an in vitro bioactivity assay. Physical characterisation also included electron microscopy, tap density measurement and laser light diffraction. The aerosol aerodynamic performance of the formulations was assessed using the Andersen cascade impactor. Based on these studies, a formulation for spray freeze-drying was selected and the effects of the two particle engineering techniques on the biophysical stability and aerosol performance of the resulting powders was determined. CD, fluorescence spectroscopy and bioactivity data suggest that trehalose when used alone as a stabilising excipient produces a superior stabilising effect than when used in combination with a non-ionic surfactant. This highlights the utility of CD and fluorescence spectroscopy studies for the prediction of protein bioactivity post-processing. Therefore, a method and formulation suitable for the preparation of PTH as a dry powder was developed based on spray-drying PTH with trehalose as a stabiliser with the bioactivity of SD PTH containing trehalose being equivalent to that of unprocessed PTH.

Lasofoxifene: Evidence of its therapeutic value in osteoporosis

Introduction:

Osteoporosis is a skeletal disorder characterized by compromised bone strength and increased risk of fracture. It is a common disorder in elderly subjects and represents a major public health problem, affecting up to 40% postmenopausal women and 15% of men. Among the several therapeutical interventions, hormone replacement therapy (HRT) was traditionally seen as the gold standard for preventing osteoporotic fractures in postmenopausal women, as well as for the management of menopausal symptoms. However HRT, especially if administered long-term, may lead to an increased risk of breast and, when unopposed by progestins, endometrial cancers. Alternative therapies include bisphosphonates and raloxifene, a selective estrogen receptor modulator (SERM). While the former have been associated with suboptimal adherence, the latter was considerably less potent than estrogen and its effect in the prevention of nonvertebral fractures remain uncertain.

Aims:

The purpose of this article is to review the clinical trials of lasofoxifene, a new SERM for the treatment of postmenopausal osteoporosis. The medical literature was reviewed for appropriate articles containing the terms “lasofoxifene” and SERMs”.

Evidence review:

There are three (phase II or phase III) clinical trials that clearly demonstrate efficacy and safety of this new SERM in the suppression of bone loss and the prevention of vertebral and nonvertebral fractures. Moreover, lasofoxifene treatment also reduced breast cancer risk and the occurrence of vaginal atrophy.

Place in therapy:

With its increased potency and efficacy on the prevention of nonvertebral fractures lasofoxifene may be an alternative and cost-effective therapy for osteoporosis in postmenopausal women.

Efficacy and cost-effectiveness of nutritional intervention in elderly after hip fracture: design of a randomized controlled trial

Background

Hip fracture patients often have an impaired nutritional status at the time of fracture, which can result in a higher complication rate, prolonged rehabilitation time and increased mortality. A study was designed to evaluate the effect of nutritional intervention on nutritional status, functional status, total length of stay, postoperative complications and cost-effectiveness.

Methods

Open-labelled, multi-centre, randomized controlled trial in hip fracture patients aged 55 years and above. The intervention group receives dietetic counselling (by regular home visits and telephone calls) and oral nutritional supplementation for three months after surgery. The control group receives usual dietetic care as provided by the hospital. Outcome assessment is performed at three and six months after hip fracture.

Discussion

Patient recruitment has started in July 2007 and has ended in December 2009. First results are expected in 2011.

Trial registration

ClinicalTrials.gov NCT00523575

[Socioeconomic costs of stroke in Korea: estimated from the Korea national health insurance claims database]

OBJECTIVES

To estimate the annual socioeconomic costs of stroke in Korea in 2005 from a societal perspective.

METHODS

We identified those 20 years or older who had at least one national health insurance (NHI) claims record with a primary or a secondary diagnosis of stroke (ICD-10 codes: I60-I69, G45) in 2005. Direct medical costs of the stroke were measured from the NHI claims records. Direct non-medical costs were estimated as transportation costs incurred when visiting the hospitals. Indirect costs were defined as patients' and caregivers' productivity loss associated with office visits or hospitalization. Also, the costs of productivity loss due to premature death from stroke were calculated.

RESULTS

A total of 882,143 stroke patients were identified with prevalence for treatment of stroke at 2.44%. The total cost for the treatment of stroke in the nation was estimated to be 3,737 billion Korean won (KRW) which included direct costs at 1,130 billion KRW and indirect costs at 2,606 billion KRW. The per-capita cost of stroke was 3 million KRW for men and 2 million KRW for women. The total national spending for hemorrhagic and ischemic stroke was 1,323 billion KRW and 1,553 billion KRW, respectively, which together consisted of 77.0% of the total cost for stroke. Costs per patient for hemorrhagic and ischemic stroke were estimated at 6 million KRW and 2 million KRW, respectively.

CONCLUSIONS

Stroke is a leading public health problem in Korea in terms of the economic burden. The indirect costs were identified as the largest component of the overall cost.

Long-term follow-up of testicular cancer patients shows no predisposition to osteoporosis

Most patients with testis cancer are cured with treatment. However, the incidence of osteoporosis after prolonged follow-up is unknown. This study investigates the incidence of osteoporosis in 39 testis cancer patients with follow-up from 5 to 28 years. There was no increased incidence of osteoporosis. These initial data are reassuring but require further investigation.

INTRODUCTION

The majority of patients with testis cancer are cured with either a unilateral orchidectomy alone or orchidectomy and chemotherapy. However, the long-term incidence of osteoporosis following treatment for testicular cancer has not been established.

METHOD

This was a single-centre cross-sectional study, where bone mineral density (BMD) measurements were performed in male patients who were previously treated for testicular cancer. BMD measurements were made by dual-energy X-ray scanning (DXA) using a HOLOGIC imaging bone densitometer. The World Health Organisation criteria were used to define osteoporosis and osteopenia. Blood samples were taken from each patient at the time of the DXA scan. Statistical analyses were performed in STATA10.

RESULTS

Neither orchidectomy alone nor orchidectomy and chemotherapy together predisposed to osteoporosis [p value = 0.4 (95%CI -0.1-0.8) and p value = 0.2 (95%CI -0.2-0.7), respectively]. Analysis also showed no evidence of an association between cases of osteopenia and length of follow-up (assessed by logistic regression).

CONCLUSION

This work found no association between treatment for testis cancer and the development of osteoporosis. Screening the whole population of testis cancer survivors for osteoporosis in the long term is not necessary; however, targeting specific patients with risk factors may be warranted.

Effects of drospirenone/estrogen combinations on bone metabolism

Bone mass is maintained when low-dose ethinylestradiol is used in combination with the new progestogen drospirenone as an oral contraceptive, making a regimen of drospirenone combined with 17beta-estradiol an attractive option for hormone replacement therapy (HRT) in postmenopausal women. Drospirenone is a novel progestogen, more closely related to endogenous progesterone in its pharmacological properties than other progestogens available; in combination with estrogen, drospirenone can closely mimic the premenopausal hormonal balance. In a phase II/III double-blind, placebo-controlled, randomized trial, three different doses of drospirenone plus low-dose 17beta-estradiol were compared with placebo, in order to determine their effects on bone density. Of 240 healthy postmenopausal women aged 45-65 years who enrolled, 180 completed the 2-year prospective study. Treatment groups received 1 mg 17beta-estradiol combined with 1, 2 or 3 mg drospirenone daily or placebo. Bone mineral densities at the lumbar spine, hip and total body and markers of bone turnover were measured at 1, 3, 6, 12, 18 and 24 months. In the pooled HRT groups, the bone mineral density at the lumbar spine, hip and total body increased by 7%, 4% and 3%, respectively, compared with placebo (all p < 0.001). Markers of bone turnover in HRT groups all decreased accordingly (serum osteocalcin 52%, serum bone-specific alkaline phosphatase 36%, serum CrossLaps 67% and urinary CrossLaps 75% from baseline; all p < 0.001). The combination of 17beta-estradiol with drospirenone offers a safe and effective medication for decreasing bone turnover and preventing postmenopausal bone loss in postmenopausal women.

Patient participation and physical activity during rehabilitation and future functional outcomes in patients after hip fracture

OBJECTIVE

To examine the association between physical activity recorded by actigraphy during therapy sessions (therapy) with therapist-rated patient participation and self-reported future functional outcomes. We hypothesized those participants who were more active during rehabilitation would have higher participation scores and better functional outcomes after hip fracture compared with those who were less active.

DESIGN

Longitudinal study with a 3- and 6-month follow-up.

SETTING

Participants were recruited from skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs).

PARTICIPANTS

Participants included 18 community-dwelling older adults admitted to SNFs or IRFs facilities after hip fracture. Participants were included if they were 60 years of age or older and ambulatory with or without assistance from a device or another person.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Physical activity was quantified during participants' rehabiliation by using the actigraph accelerometer worn consecutively over 5 days. The Pittsburgh Participation Rating Scale was used to quantify patient participation during their inpatient therapy sessions. Self-reported functional outcomes were measured by the Hip Fracture Functional Recovery Scale at baseline and 3 and 6 months after fracture.

RESULTS

Participants with higher actigraphy counts during rehabilitation were ranked by their therapists as having excellent participation compared with those who were less active. Participants who were more active reported better functional abilities at both the 3- and 6-month time points and achieved 78% and 91% recovery of self-reported prefracture function compared with those who were less active achieving 64% and 73% recovery.

CONCLUSIONS

Actigraphy provides an objective measure of physical activity exhibiting predictive validity for future functional outcomes and concurrent validity against patient participation in patients after hip fracture.

Osteoporotic fractures and hospitalization risk in chronic spinal cord injury

Osteoporosis is a well acknowledged complication of spinal cord injury. We report that motor complete spinal cord injury and post-injury alcohol consumption are risk factors for hospitalization for fracture treatment. The clinical assessment did not include osteoporosis diagnosis and treatment considerations, indicating a need for improved clinical protocols.

INTRODUCTION

Treatment of osteoporotic long bone fractures often results in lengthy hospitalizations for individuals with spinal cord injury. Clinical features and factors that contribute to hospitalization risk have not previously been described.

METHODS

Three hundred and fifteen veterans > or = 1 year after spinal cord injury completed a health questionnaire and underwent clinical exam at study entry. Multivariate Cox regression accounting for repeated events was used to assess longitudinal predictors of fracture-related hospitalizations in Veterans Affairs Medical Centers 1996-2003.

RESULTS

One thousand four hundred and eighty-seven hospital admissions occurred among 315 participants, and 39 hospitalizations (2.6%) were for fracture treatment. Median length of stay was 35 days. Fracture-related complications occurred in 53%. Independent risk factors for admission were motor complete versus motor incomplete spinal cord injury (hazard ratio = 3.73, 95% CI = 1.46-10.50). There was a significant linear trend in risk with greater alcohol consumption after injury. Record review indicated that evaluation for osteoporosis was not obtained during these admissions.

CONCLUSIONS

Assessed prospectively, hospitalization in Veterans Affairs Medical Centers for low-impact fractures is more common in motor complete spinal cord injury and is associated with greater alcohol use after injury. Osteoporosis diagnosis and treatment considerations were not part of a clinical assessment, indicating the need for improved protocols that might prevent low-impact fractures and related admissions.

Bazedoxifene for the prevention of postmenopausal osteoporosis

Bazedoxifene acetate is a novel, chemically distinct selective estrogen receptor modulator (SERM) that has been specifically developed after a stringent preclinical screening in order to obtain favorable effects on the skeleton and lipid metabolism with the additional improvement of a neutral effect on hot flushes and without stimulating the uterus or the breast. In both preclinical and clinical studies this SERM was shown to maintain BMD, prevent fractures, and reduce total cholesterol. Moreover, bazedoxifene also showed an improved uterine profile and demonstrated estrogen antagonistic activity on the endometrium. Importantly, this latter capacity has led to the development of a novel class of menopausal therapy called tissue selective estrogen complex (TSEC), in which bazedoxifene is combined with conjugated estrogen. The rationale for selecting bazedoxifene as the SERM in this TSEC combination is that it may offset estrogen stimulation of endometrial and breast tissue, without the necessity of using a progestin in women with an intact uterus, without aggravating menopausal vasomotor symptoms, but with an additive effect on bone. Preliminary data from phase 3 clinical trials appear to confirm this hypothesis, showing a greater effect of bazedoxifene on BMD with respect to raloxifene, coupled with efficacy on menopausal vasomotor symptoms not achieved by SERM alone. These properties and the safety profile of this combination, if confirmed long-term in ongoing phase 3 trials, might significantly affect the way women and physicians approach menopause and its related disorders.

[Estimating the economic burden of osteoporotic vertebral fracture among elderly Korean women]

OBJECTIVES

To estimate the economic burden of osteoporotic vertebral fracture (VF) from a societal perspective.

METHODS

From 2002 to 2004, we identified all National Health Insurance claims records for women >or= 50 years old with a diagnosis of VF. The first 6-months was defined as a "clearance period," Ysuch that patients were considered as incident cases if their first claim of fracture was recorded after June 30, 2002. We only included patients with >or= one claim of a diagnosis of, or prescription for, osteoporosis over 3 years. For each patient, we cumulated the claims amount for the first visit and for the follow-up treatments for 1 year. The hospital charge data from 4 hospitals were investigated to measure the proportion of the non-covered services. Face-to-face interviews were conducted with 106 patients from the 4 study sites to measure the out-of-pocket spending outside of hospitals.

RESULTS

During 2.5 years, 131,453 VF patients were identified. The patients had an average of 3.38 visits, 0.40 admissions and 6.36 inpatient days. The per capita cost was 1,909,690 Won: 71.5% for direct medical costs, 20.6% for direct non-medical costs and 7.9% for indirect costs. The per capita cost increased with increasing age: 1,848,078 Won for those aged 50-64, 2,084,846 Won for 65-74, 2,129,530 Won for 75-84 and 2,121,492 Won for those above 84.

CONCLUSIONS

Exploring the economic burden of osteoporotic VF is expected to motivate to adopt effective treatment options for osteoporosis in order to prevent the incidence of fracture and the consequent costs.

Impact of compliance and persistence with bisphosphonate therapy on health care costs and utilization

The impact of persistence and compliance with bisphosphonate therapy on health care costs and utilization was examined in women newly prescribed bisphosphonates. At 3 years, women who were persistent and compliant with bisphosphonate therapy had lower total costs compared with non-persistent and non-compliant women, after controlling for relevant risk factors.

INTRODUCTION

The impact of persistence and compliance with bisphosphonate therapy on health care costs and utilization was examined in bisphosphonate-naïve women.

METHODS

Two claims databases were used to identify women > or = 45 years of age and who filled a new bisphosphonate prescription during 2000-2002. Persistence and compliance were evaluated over 3 years. Compliance was defined as a medication possession ratio (days of bisphosphonate supply/days of follow-up) > or = 0.80; persistence was defined as no refill gaps > or = 30 days. Multivariate models accounted for potential confounders.

RESULTS

This analysis included 32,944 women (mean age, 64 years) who filled a new prescription for daily or weekly alendronate (n = 26,581) or risedronate (n = 6,363). At 3 years, 37% of women were compliant and 21% of women were persistent. Unadjusted total mean health care costs were lower for the compliant vs. non-compliant and persistent vs. non-persistent cohorts. After adjusting for potential confounders, total health care costs were reduced by 8.9% for persistent patients (p < 0.001) and 3.5% for compliant patients (p = 0.014). Persistence decreased the likelihood of inpatient admission by 47%.

CONCLUSION

At 3 years, women who were persistent and compliant with bisphosphonate therapy had lower total costs compared with non-persistent and non-compliant women, after controlling for relevant risk factors.

Autosome-wide linkage analysis of hip structural phenotypes in the Old Order Amish

INTRODUCTION

Fracture risk is associated with bone mineral density (BMD) and with other indices of bone strength, including hip geometry. While the heritability and associated fracture risk of BMD are well described, less is known about genetic influences of bone geometry. We derived hip structural phenotypes using the Hip Structural Analysis program (HSA) and performed autosome-wide linkage analysis of hip geometric structural phenotypes.

MATERIALS AND METHODS

The Amish Family Osteoporosis Study was designed to identify genes affecting bone health. BMD was measured at the hip using dual X-ray absorptiometry (DXA) in 879 participants (mean age+/-SD=49.8+/-16.1 years, range 18-91 years) from large multigenerational families. From DXA scans, we computed structural measures of hip geometry at the femoral neck (NN) and shaft (S) by HSA, including cross-sectional area (CSA), endocortical or inner diameter (ID), outer diameter (OD) buckling ratio (BR) and section modulus (Z). Genotyping of 731 highly polymorphic microsatellite markers (average spacing of 5.4 cM) and autosome-wide multipoint linkage analysis was performed.

RESULTS

The heritability of HSA-derived hip phenotypes ranged from 40 to 84%. In the group as a whole, autosome-wide linkage analysis suggested evidence of linkage for QTLs related to NN_Z on chromosome 1p36 (LOD=2.36). In subgroup analysis, ten additional suggestive regions of linkage were found on chromosomes 1, 2, 5, 6, 11, 12, 14, 15 and 17, all with LOD>2.3 except for our linkage at 17q11.2-13 for men and women age 50 and under for NN_CSA, which had a lower LOD of 2.16, but confirmed a previous linkage report.

CONCLUSIONS

We found HSA-derived measures of hip structure to be highly heritable independent of BMD. No strong evidence of linkage was found for any phenotype. Confirmatory evidence of linkage was found on chromosome 17q11.2-12 for NN_CSA. Modest evidence was found for genes affecting hip structural phenotypes at ten other chromosomal locations.

Soy isoflavones in the management of postmenopausal osteoporosis

This is a review article designed to address the effects of soy isoflavones on bone metabolism in postmenopausal women and their place in the prevention and treatment of postmenopausal osteoporosis. Soy isoflavones are natural products that could be used as an alternative to menopausal hormone therapy because they are structurally and functionally related to 17beta-estradiol. In vitro and animal studies have shown that they act in multiple ways to exert their bone-supporting effects. They act on both osteoblasts and osteoclasts through genomic and nongenomic pathways. Epidemiological studies and clinical trials suggest that soy isoflavones have beneficial effects on bone mineral density, bone turnover markers, and bone mechanical strength in postmenopausal women. However, there are conflicting results related to differences in study design, estrogen status of the body, metabolism of isoflavones among individuals, and other dietary factors. The long-term safety of soy isoflavone supplements remains to be demonstrated.

Prevalence of osteoporosis in middle Anatolian population using calcaneal ultrasonography method

BACKGROUND

There are a few studies on the prevalence of osteoporosis in Turkey. Most of such studies have been performed using classical diagnostic methods. Quantitative calcaneal ultrasonography is a contemporary procedure used in the diagnosis of osteoporosis.

OBJECTIVE

The aim of this study is to determine the prevalence of the osteoporosis and risk factors in middle Anatolian population aged more than 40, using quantitative calcaneal ultrasonography.

SUBJECTS AND METHODS

The present study was carried out in rural and urban areas of primary health care units. Evaluation of skeletal status was based on calcaneal quantitative ultrasound measurement, carried out by the Sahara Clinical Bone Sonometer (Hologic Waltham, MA, USA).

RESULTS

There were 1437 individuals, 866 were females (60.3%) and 571 were males (39.7%), aged in between 40 and 89 years. Standardized prevalence rates using Segi's population were found to be 14.0% in total, 17.1% in female and 9.2% in male. Osteoporosis prevalence increased with increasing ages. The highest prevalence value was determined in the individuals older than 70 years of age. Osteoporosis was more common among women compared to men. Osteoporosis prevalence increased in consistent with a decrease in the amount of milk, yoghurt and cheese consumption.

CONCLUSION

Based on current study, it is concluded that osteoporosis is an important health problem. Requiring health education about life styles (activity and nutrition) to avoid and even control osteoporosis.

Unipedicular vertebroplasty for osteoporotic compression fracture using an individualized needle insertion angle

OBJECTIVES

In the classic transpedicular vertebroplasty, second needle placement is routinely required at the same level. However, each patient requires a different needle insertion angle (NIA) at each site. Therefore, precise NIA is required for each fractured vertebral body. In this study, we performed a unipedicular approach through an individualized NIA that had been evaluated with axial magnetic resonance imaging before vertebroplasty.

METHODS

We performed percutaneous vertebroplasty (PVP) on 103 vertebrae in 63 consecutive patients (50 women, 13 men; mean age, 70.4 y; range, 56 to 87 y). Before PVP, we measured the NIA for each pedicle. If leakage occurred without midline cement crossover, the unipedicular approach was stopped and changed to a bipedicular approach.

RESULTS

PVPs were performed from T7 to L5. We considered a successful outcome of a unipedicular approach to be when the center of vertebral body was filled with cement. Successful unipedicular PVPs were performed in 93 (90.3%) of 103 cases. Fifty-six of 63 patients were included for the pain evaluation. There was a statistically significant difference (P<0.0001) between pre-visual analog scale (VAS) (84) and post-VAS (postoperatively at 1 d-VAS: 32, postoperatively at 1 mo-VAS: 34, and postoperatively at 3 mo-VAS: 37). No statistically significant difference was found between pre-NIAs and post-NIAs. A positive correlation was found between pre-NIAs and post-NIAs.

DISCUSSION

Unipedicular PVP can be performed safely, provided the operator has a thorough knowledge of the bony landmarks and the anatomy of the pedicle. A unipedicular approach could be considered first using individualized NIA at each vertebral level.

[Malnutrition as a prognostic factor in elderly patients with hip fractures]

BACKGROUND AND OBJECTIVE

Hip fracture occurs frequently in elderly patients, with devastating effects on the quality of life due to the high financial burden and the high mortality rate in patients with this condition. Malnutrition is prevalent in the elderly and it can negatively influence patients' recovery from hip fracture. Our proposal was to assess the relationship between malnutrition and the recovery of patients with hip fracture.

PATIENTS AND METHOD

A total of 110 patients with hip fractures who were admitted to the orthopedic unit at the Reina Sofía Hospital were reassessed one year after discharge. A prospective cohort design and logistic regression analysis was used.

RESULTS

Mean age was 81.4, and 80% of patients were women. After one year 19.7% of patients had died. A multivariate analysis showed a significant relationship between a poor functional recovery and age (odds ratio [OR] = 1.19), caloric malnutrition (OR = 290), protein malnutrition (OR = 125); and there was a significant relationship between being confined to bed and a worse situation before fracture (OR = 10.02); caloric malnutrition (OR = 9.57) and protein malnutrition (OR = 15.23).

CONCLUSIONS

Caloric and protein malnutrition were associated with a worse functional recovery in elderly patients with hip fracture.

Influence of obesity on bone density in postmenopausal women

OBJECTIVE: To evaluate the influence of obesity, age, and years since menopause on bone density. METHODS: A retrospective analysis of bone mineral density (BMD) obtained from 588 women, 41 to 60 years, previously menopaused (1-10 years before). RESULTS: Positive influence of obesity was confirmed by the significant differences in BMD at lumbar spine, femoral neck (FN), and trochanter (TR) between the groups (p < 0.01). Age and years since menopause (YSM) were negatively correlated with BMD at all sites (p = 0.000). Comparing patients within 1 to < 6 YSM versus 6 to 10 YSM, BMD was higher in the former at LS and FN (p < 0.005), despite the higher BMI in the older group (p = 0.01). Obese patients had a lower prevalence of osteoporosis at LS and FN (p = 0.009). Regression analysis identified BMI as the strongest determinant of FN and TR BMD, while YSM was the strongest determinant of LS BMD. CONCLUSION: The protective effect of obesity is overtaken by age and estradiol deficiency. We recommend that even obese postmenopausal women should be screened for osteoporosis.