Bisphosphonate treatment of osteoporosis

Mining and analysis of adverse event signals for alendronate based on the real-world data of FDA adverse event reporting system database

OBJECTIVE

Our study aims to assess alendronate-related adverse events (AEs) from the US FDA adverse event reporting system database.

METHODS

The AE data associated with alendronate between the first quarter of 2004 and the first quarter of 2024 were selected. Various signal quantification methods, including the ROR, PRR, BCPNN, and EBGM, were applied for analysis.

RESULTS

In 34,943 reports where alendronate was the primary suspected drug for the AE, 24 affected system organ classes and 1046 significant preferred terms were identified in this study. Several significant AEs beyond drug instructions with strong signals were determined, including low turnover osteopathy, fracture delayed union, fracture nonunion, loss of anatomical alignment after fracture reduction, fracture malunion, periprosthetic fracture, carotid bruit, oral fibroma, traumatic occlusion, and phlebolith. The median time to onset of alendronate-related AEs was 306 days (interquartile range [IQR] 12-1,461 days), and the majority of cases occurred 2 years later (18.80%) and within 30 days (14.49%).

CONCLUSIONS

The current study detected multiple potential new AE signals for alendronate, and more clinical research is required to further validate our results and clarify their associations.

Development of 3-acetylindole derivatives that selectively target BRPF1 as new inhibitors of receptor activator of NF-κB ligand (RANKL)-Induced osteoclastogenesis

Bromodomain and PHD finger-containing (BRPF) proteins function as epigenetic readers that specifically recognize acetylated lysine residues on histone tails. The acetyl-lysine binding pocket of BRPF has emerged as an attractive target for the development of protein interaction inhibitors owing to its potential druggability. In this study, we identified 3-acetylindoles as bone antiresorptive agents with a novel scaffold by performing structure-based virtual screening and hit optimization. Among those derivatives, compound 18 exhibited potent and selective inhibitory activities against BRPF1B (IC50 = 102 nM) as well as outstanding inhibitory activity against osteoclastogenesis (73.8% @ 1 μM) and differentiation (IC50 = 0.19 μM) without cytotoxicity. Besides, cellular mechanism assays demonstrated that compound 18 exhibited a strong bone antiresorptive effect by modulating the RANKL/RANK/NFATc1 pathway. Structural and functional studies on BRPF1 inhibitors aid in making advances to understand the epigenetic mechanisms of bone cell development and create innovative therapeutics for treating bone metastases from solid tumors and other bone erosive diseases.

American Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws-2022 Update

Strategies for management of patients with, or at risk for, medication-related osteonecrosis of the jaws (MRONJ) - formerly referred to as bisphosphonate-related osteonecrosis of the jaws (BRONJ)-were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position papers in 2007, 2009 and 2014. The position papers were developed by a committee appointed by the AAOMS Board of Trustees and comprising clinicians with extensive experience in caring for these patients, as well as clinical and basic science researchers. The knowledge base and experience in addressing MRONJ continues to evolve and expand, necessitating modifications and refinements to the previous position papers. Three members of the AAOMS Committee on Oral, Head, and Neck Oncologic and Reconstructive Surgery (COHNORS) and three authors of the 2014 position paper were appointed to serve as a working group to analyze the current literature and revise the guidance as indicated to reflect current knowledge in this field. This update contains revisions to diagnosis and management strategies and highlights the current research status. AAOMS maintains that it is vitally important for this information to be disseminated to other relevant healthcare professionals and organizations.

The incidence of medication-related osteonecrosis of the jaw following tooth extraction in patients prescribed oral bisphosphonates

Aims To determine the incidence of medication-related osteonecrosis of the jaw in patients prescribed oral bisphosphonate medication following dental extraction in a dedicated clinic within the Department of Oral Surgery of King's College Hospital. The effect of factors such as sex, duration of therapy, medical comorbidities and site of extraction, which have previously been reported to significantly affect the risk of developing osteonecrosis of the jaw, was also examined.Materials and methods Data were gathered from the dental records of patients who had extractions over an eight-year period and were included in this retrospective study. Patients with previous or current exposure to intravenous bisphosphonates, denosumab, novel-targeted chemotherapies used in the oncology setting or radiotherapy to the head and neck were excluded from this study.Results The incidence of medication-related osteonecrosis of the jaw following tooth extraction in this group of 652 was 0.8%. A significantly increased risk of developing medication-related osteonecrosis of the jaw was evident in patients prescribed oral bisphosphonates for four years or more (p = 0.02), with an incidence in this group of 1.6%.Conclusion This study demonstrates that, following dental extraction, patients who are prescribed oral bisphosphonates are at risk of developing medication-related osteonecrosis of the jaw and that this risk increases significantly when the patient has been taking the bisphosphonate for four years or more.

Spatiotemporally controlled calcitonin delivery: Long-term and targeted therapy of skeletal diseases

Bone is a connective tissue that support the entire body and protect the internal organs. However, there are great challenges on curing intractable skeletal diseases such as hypercalcemia, osteoporosis and osteoarthritis. To address these issues, calcitonin (CT) therapy is an effective treatment alternative to regulate calcium metabolism and suppress inflammation response, which are closely related to skeletal diseases. Traditional calcitonin formulation requires frequent administration due to the low bioavailability resulting from the short half-life and abundant calcitonin receptors distributed through the whole body. Therefore, long-term and targeted calcitonin delivery systems (LCDS and TCDS) have been widely explored as the popular strategies to overcome the intrinsic limitations of calcitonin and improve the functions of calcium management and inflammation inhibition in recent years. In this review, we first explain the physiological effects of calcitonin on bone remodeling: (i) inhibitory effects on osteoclasts and (ii) facilitated effects on osteoblasts. Then we summarized four strategies for spatiotemporally controlled delivery of calcitonin: micro-/nanomedicine (e.g. inorganic micro-/nanomedicine, polymeric micro-/nanomedicine and supramolecular assemblies), hydrogels (especially thermosensitive hydrogels), prodrug (PEGylation and targeting design) and hybrid biomaterials. Subsequently, we discussed the application of LCDS and TCDS in treating hypercalcemia, osteoporosis, and arthritis. Understanding and analyzing these advanced calcitonin delivery applications are essential for future development of calcitonin therapies toward skeletal diseases with superior efficacy in clinic.

Pharyngeal spreading of peri-implant infections under antiresorptive/antiangiogenic therapy

Objectives

To assess the influence of antiresorptive/antiangiogenic therapy on the spreading of peri-implant infections in the pharyngeal region.

Material and methods

This analysis was based on tissue biopsies obtained from a total of twenty-five albino rats having either received (1) amino-bisphosphonate (Zoledronate) (Zo) (n=4), (2) RANKL inhibitor (Denosumab) (De) (n=4), (3) antiangiogenic medication (Bevacizumab) (Be) (n=4), (4) Zo+Be (n=3), (5) De+Be (n=5), or (6) no medication (Co) (n=5). Drug administration was repeated at 12 weeks. Chronic-type peri-implant infections were induced at titanium implants located in the upper jaws. The surface area (%) of infiltrated connective tissue (ICT) and CD68-positive cells was assessed within the lateral pharyngeal/retropharyngeal connective tissue zone.

Results

Mean (±SD) and median ICT% values and CD68 counts were markedly highest in the De+Be (11.10±6.04; 11.81; 95% CI − 3.89; 26.11) and De (5.70±5.06; 6.19; 95% CI − 2.34; 13.75) groups, reaching statistical significance for De CD68 counts over the Co (0.18±0.25; 0.18; 95% CI −2.14; 2.51) group. In both De+Be and De groups, the ICTs were occasionally associated with an ulceration of the epithelial compartment.

Conclusions

Induced peri-implant infections were not associated with any inflammatory lesions in pharyngeal tissues. While these findings were similar under Zo and Be medication, De and De+Be had a marked effect on ICT and CD68 values. The clinical relevance of these adverse findings needs further investigation.

Success Rate and Safety of Dental Implantology in Patients Treated With Antiresorptive Medication: A Systematic Review

There is no agreement of data on the subject of implant failure and the development of osteonecrosis in patients receiving antiresorptive agents. The purpose of this systematic review is to evaluate whether dental implants placed in patients on antiresorptive medication have an increased failure rate and whether the implant placement or the implant existence are risk factors for developing medication-related osteonecrosis of the jaw (MRONJ). An electronic search was conducted in PubMed/Medline, and all publications fulfilling the inclusion criteria were included. The search was completed by a hand research of the references cited in all electronic identified publications, resulting in 411 articles. Based on the inclusion criteria, 32 studies were included, with a total of 5221 patients, 12 751 implants, 618 cases of implants loss, and 136 cases of MRONJ analyzed. Because of the small number of studies, most of which were characterized by a low level of quality, it cannot be established that the use of antiresorptive medication affects dental implant survival rates. The risk of MRONJ as an early or late complication is also not well established. Therefore, successful dental implant procedures in patients receiving antiresorptive medication might be possible, but more studies need to be carried out in the future to verify this topic. Apart from intravenous antiresorptive drugs, which remain an absolute contraindication, the use of antiresorptive medication is not a contraindication to dental implantology, but it must be accompanied by careful treatment planning, informing patients about possible complications, and essential long follow-up periods.

Medication-related osteonecrosis and osteoradionecrosis of the jaws: Update and current management

Medication related osteonecrosis of the jaws (MRONJ) and osteoradionecrosis of the jaws (ORNJ) are two different diseases of quite similar appearance. MRONJ is mainly due to antiresorptive or antiangiogenic drug therapy and ORNJ to radiotherapy. The present work aimed at presenting and comparing the current knowledge on MRONJ and ORNJ. They both present as an exposure of necrotic bone and differ in some clinical or radiological characteristics, clinical course and mostly in treatment. They share similar risk factors. A tooth extraction is more frequently found as a triggering factor in MRONJ. The frequency of a maxillary localisation seems higher for MRONJ. On computed tomographic images, a periosteal reaction seems characteristic of MRONJ. More frequent pathological fractures seem to occur in ORNJ. It is mandatory, for ORNJ diagnosis, to exclude a residual or recurrent tumour using histological examination. Both MRONJ and ORNJ are challenging to treat and cannot be managed similarly. For both, it would still be worth to optimise awareness within the medical community, patients' oral hygiene and dental cares to improve their prevention and make their incidences decrease. Conservative therapy is more frequently achieved for MRONJ than ORNJ and surgical resection is more often performed for ORNJ. For both diseases, the last treatment possible in refractory cases is a surgical extensive resection with free flap reconstruction. A MRONJ classification is widely used today, whereas no consensus exists to date for ORNJ classification. We propose a classification that could play this role.

Knowledge, Attitude, and Management of General Dentist toward Medication-related Osteonecrosis of the Jaws

Background:

Medication-related osteonecrosis of the jaw (MRONJ) is an intense negative drug response causing increasing bone destruction in the maxillofacial area of patients.

Aims and Objectives:

To evaluate the knowledge and attitude of dental practitioner regarding risk factors of MRONJ in Saudi Arabia.

Materials and Methods:

A cross-sectional, questionnaire survey was carried out in King Khalid Hospital, Al-Kharj among dental practioners.

Results:

Approximately 60% of the practioners had a poor knowledge and there was a weak positive correlation with work experience.

Conclusion:

Poor knowledge regarding the MRONJ invites a continuing dental education specially to focus on general practioners.

Clinical characteristics and recurrence-related factors of medication-related osteonecrosis of the jaw

OBJECTIVES

The purpose of this study was to investigate the demographic and clinical characteristics of patients with medication-related osteonecrosis of the jaw (MRONJ) and to elucidate factors affecting recurrence in surgical treatment.

MATERIALS AND METHODS

A total of 51 patients who were diagnosed with MRONJ were analyzed according to demographic and clinical features and treatment results through a retrospective chart review from 2013 to 2017 in the Department of Oral and Maxillofacial Surgery, Korea University Anam Hospital, Seoul in Korea.

RESULTS

Alendronate composed the majority of medication doses (55.6%), followed by ibandronate (20.0%), risedronate (15.6%), and zoledronate (6.7%). Forty patients (88.9%) were given oral medication, and five patients (11.1%) were intravenously treated, and the mean duration of medication use was 61.1±42.9 months. A total of 10 patients (22.2%) had a drug holiday before MRONJ-induced dental treatment lasting an average of 6.8±7.0 months. MRONJ occurred 2.7 times more in the mandible, with 41 cases (73.2%) occurring in the mandible and 15 cases (26.8%) occurring in the maxilla, and the prevalence of affected posterior parts (premolar-molar) was six times greater than that of the anterior parts (incisor-canine) (48 cases vs 8 cases, 85.7% vs 14.3%). The most common dental cause of MRONJ was tooth extraction (69.6%). Regarding recurrence, there was no statistical difference in recurrence rate according to either site or stage. However, recurrence occurred in 4 out of 34 cases (11.8%) in the primary closure group and 9 out of 20 cases (45.0%) in the secondary healing group, and there was a statistical difference with respect to closure technique.

CONCLUSION

The identified risk factors in patients taking bone resorption inhibitors can aid dental clinicians in ensuring prevention and proper treatment of MRONJ.

Presenting a Method to Improve Bone Quality Through Stimulation of Osteoporotic Mesenchymal Stem Cells by Low-Level Laser Therapy

OBJECTIVE

This review aims to present a method to improve bone quality through stimulation of osteoporotic mesenchymal stem cells (MSCs) by low-level laser therapy (LLLT).

BACKGROUND

Osteoporosis (OP) is characterized by decreased bone mass and bone strength, which results in an increased incidence of bone fractures. These fractures often lead to additional disability and mortality. Osteoporotic MSCs have reduced osteogenic differentiation when cultured in their standard differentiation media. LLLT has a biostimulatory effect on fibroblasts and osteoblasts. MSCs have the ability to generate cells of connective tissue lineages, which includes the bones. Recently, transplantation of in vitro cultured bone marrow (BM) MSCs into sites at risk for development of osteoporotic bone has resulted in improved bone structure.

METHODS

Comprehensive research was performed using PubMed, and biostimulatory effect of LLLT on bony cells and MSCs were studied.

RESULTS

LLLT can stimulate growth, proliferation, and differentiation of SCs in vitro and in vivo. This ability of LLLT is an essential prerequisite for performing experiments related to disease control in humans. Thus, laser-treated osteoporotic autologous BMMSCs may represent a promising therapeutic method to protect the bones in patients with OP and prevent fractures in these patients. Therefore, researchers hypothesize that transplantation of in vitro laser-treated autologous cultured osteoporotic BMMSCs that have the appropriate osteogenic phenotype into sites at risk for development of osteoporotic bone may result in improved bone structure. In this respect, investigators have successfully used LLLT to restore autologous osteoporotic MSCs in vitro. Subsequently, these cells have been differentiated into osteoblast cell lines with the use of laser treatment after which they were transplanted into osteoporotic animal models.

CONCLUSIONS

This technique might improve bone quality and structure. However, additional research must be undertaken to understand the underlying mechanisms of this treatment, validate its effectiveness, and assess the feasibility for clinical application of LLLT to treat MSCs in regeneration of osteoporotic bone.

Dihydroartemisinin prevents breast cancer-induced osteolysis via inhibiting both breast caner cells and osteoclasts

Bone is the most common site of distant relapse in breast cancer, leading to severe complications which dramatically affect the patients’ quality of life. It is believed that the crosstalk between metastatic breast cancer cells and osteoclasts is critical for breast cancer-induced osteolysis. In this study, the effects of dihydroartemisinin (DHA) on osteoclast formation, bone resorption, osteoblast differentiation and mineralization were initially assessed in vitro, followed by further investigation in a titanium-particle-induced osteolysis model in vivo. Based on the proved inhibitory effect of DHA on osteolysis, DHA was further applied to MDA-MB-231 breast cancer-induced mouse osteolysis model, with the underlying molecular mechanisms further investigated. Here, we verified for the first time that DHA suppressed osteoclast differentiation, F-actin ring formation and bone resorption through suppressing AKT/SRC pathways, leading to the preventive effect of DHA on titanium-particle-induced osteolysis without affecting osteoblast function. More importantly, we demonstrated that DHA inhibited breast tumor-induced osteolysis through inhibiting the proliferation, migration and invasion of MDA-MB-231 cells via modulating AKT signaling pathway. In conclusion, DHA effectively inhibited osteoclastogenesis and prevented breast cancer-induced osteolysis.

Novel inhibitors of RANKL-induced osteoclastogenesis: Design, synthesis, and biological evaluation of 6-(2,4-difluorophenyl)-3-phenyl-2H-benzo[e][1,3]oxazine-2,4(3H)-diones

A series of novel 6-(2,4-difluorophenyl)-3-phenyl-2H-benzo[e][1,3]oxazine-2,4(3H)-dione derivatives were synthesized and evaluated for their inhibitory effects on osteoclast activities by using TRAP-staining assay. Among the tested compounds, 3d and 3h exhibited more potent osteoclast-inhibitory activities than the lead compound NDMC503 (a ring-fused structure of NDMC101), as reported in our previous study. Both 3d and 3h exhibited two-fold increase in activity compared to NDMC503. In addition, our biological results indicated that 3d and 3h could suppress RANKL-induced osteoclastogenesis-related marker genes, such as NFATc1, c-fos, TRAP, and cathepsin K. Notably, 3d could significantly attenuate the bone-resorbing activity of osteoclasts in the pit formation assay. Thus, this study might provide a new class of lead structures that warrant further development as potential anti-resorptive agents.

Comparison of the prognosis of bisphosphonate-related osteonecrosis of the jaw caused by oral and intravenous bisphosphonates

Bisphosphonates (BPs) have been used in medical practice for the treatment of osteoporosis, bone metastasis, and multiple myeloma. Although many studies have been published, the treatment and prognosis of bisphosphonate-related osteonecrosis of the jaw (BRONJ) remain unclear. This study included 59 patients with BRONJ: 29 had taken oral BPs and 30 had taken intravenous (IV) BPs. All received conservative treatments. When separated sequestra were seen, a sequestrectomy was performed. Segmental mandibular resection was performed when pathological fractures were diagnosed. The outcomes of treatments were compared between groups. For patients treated with oral rinses or mandibular resection, the number in whom clinical healing was observed did not differ between the oral BP and IV BP groups. With regard to sequestrectomy, 94% of patients in the oral BP group showed improvement with this treatment compared to 50% in the IV BP group. The number of patients in whom clinical healing of BRONJ was achieved was statistically better in the oral BP group than in the IV BP group after 6 months of treatment (P<0.001). The results showed that >90% of patients treated with oral BPs could be cured. However, 50% of patients treated with IV BPs did not show an improvement. Additional research is needed to further increase the therapeutic efficacy for the resolution of BRONJ.

Effect of Fermented Red Ginseng Extract Enriched in Ginsenoside Rg3 on the Differentiation and Mineralization of Preosteoblastic MC3T3-E1 Cells

In this study, red ginseng extract (RGE) was converted into high-content minor ginsenosides by fermenting with Bgp1 enzymes at 37°C for 5 days. Compared to the RGE, the minor ginsenoside contents were increased in fermented red ginseng extract (FRGE). Moreover, the amount of minor ginsenosides such as Rh1 (11%) and Rg2 (16%) was slightly augmented, while the level of Rg3 (33%) was significantly increased after bioconversion. Furthermore, we also examined and compared the effect of RGE and FRGE on the differentiation and mineralization of preosteoblastic MC3T3-E1 cells. Similarly, the level of mRNA expression of intracellular alkaline phosphatase (ALP) activity, type-1 collagen (Col-I) was also increased. Based on the comparison, it is clear that the FRGE has improved effects on bone formation and differentiation of preosteoblastic MC3T3-E1 cells.

The inhibitory effect of zoledronate on early-stage osteoinduction by recombinant human bone morphogenetic protein 2 in an osteoporosis model

This study evaluated the effect of the combined treatment of intravenous zoledronic acid (ZA, 0.08 mg/kg) and rhBMP-2 (5 µg) on osteogenesis in a calvarial defect model of ovariectomized SD rats. New bone formation was evaluated 4 or 8 weeks after calvarial defect implantation using micro-CT and histology. Micro-CT results revealed that the rhBMP-2 group showed significantly higher calvarial defect coverage ratio compared with the ZA + rhBMP-2 group at 4 weeks. In addition, bone formation indices were significantly lower in ZA + rhBMP-2 group when compared with the rhBMP-2 group after 4 weeks, which indicates a negative effect of ZA on the initial bone formation and the bone quality. At 8 weeks, the negative effect induced by ZA treatment was alleviated as time passed. Histological examination showed similar results to the micro-CT measurements. In conclusion, although ZA treatment lowered the new bone formation induced by rhBMP-2 initially, as time passed, the negative effect was decreased.

Modified salicylanilide and 3-phenyl-2H-benzo[e][1,3]oxazine-2,4(3H)-dione derivatives as novel inhibitors of osteoclast differentiation and bone resorption

Inhibition of osteoclast formation is a potential strategy to prevent inflammatory bone resorption and to treat bone diseases. In the present work, the purpose was to discover modified salicylanilides and 3-phenyl-2H-benzo[e][1,3]oxazine-2,4(3H)-dione derivatives as potential antiosteoclastogenic agents. Their inhibitory effects on RANKL-induced osteoclastogenesis from RAW264.7 cells were evaluated by TRAP stain assay. The most potent compounds, 1d and 5d, suppressed RANKL-induced osteoclast formation and TRAP activity dose-dependently. The cytotoxicity assay on RAW264.7 cells suggested that the inhibition of osteoclastic bone resorption by these compounds did not result from their cytotoxicity. Moreover, both compounds downregulated RANKL-induced NF-κB and NFATc1 in the nucleus, suppressed the expression of osteoclastogenesis-related marker genes during osteoclastogenesis, and prevented osteoclastic bone resorption but did not impair osteoblast differentiation in MC3T3-E1. Therefore, these modified salicylanilides and 3-phenyl-2H-benzo[e][1,3]oxazine-2,4(3H)-diones could be potential lead compounds for the development of a new class of antiresorptive agents.

Andrographolide prevents human breast cancer-induced osteoclastic bone loss via attenuated RANKL signaling

Bone metastasis is a common and serious complication in advanced cancers such as breast cancer, prostate cancer, and multiple myeloma. Agents that prevent bone loss could be used to develop an alternative therapy for bone metastasis. RANKL, a member of the tumor necrosis factor superfamily, has been shown to play a significant role in cancer-associated bone loss. In this study, we examined the efficacy of the natural compound andrographolide (AP), a diterpenoid lactone isolated from the traditional Chinese and Indian medicinal plant Andrographis paniculata, in reducing breast cancer-induced osteolysis. AP prevented human breast cancer-induced bone loss by suppressing RANKL-mediated and human breast cancer cell-induced osteoclast differentiation. Molecular analysis revealed that AP prevented osteoclast function by inhibiting RANKL-induced NF-κB and ERK signaling pathway in lower dose (20 μM), as well as inducing apoptosis at higher dose (40 μM). Thus, AP is a potent inhibitor of breast cancer-induced bone metastasis.

Drug-induced uveitis

A number of medications have been associated with uveitis. This review highlights both well-established and recently reported systemic, topical, intraocular, and vaccine-associated causes of drug-induced uveitis, and assigns a quantitative score to each medication based upon criteria originally described by Naranjo and associates.

Structure of Acid phosphatases

Acid phosphatases are enzymes that have been studied extensively due to the fact that their dysregulation is associated with pathophysiological conditions. This characteristic has been exploited for the development of diagnostic and therapeutic methods. As an example, prostatic acid phosphatase was the first marker for metastatic prostate cancer diagnosis and the dysregulation of tartrate resistant acid phosphatase is associated with abnormal bone resorption linked to osteoporosis. The pioneering crystallization studies on prostatic acid phosphatase and mammalian tartrate-resistant acid phosphatase conformed significant milestones towards the elucidation of the mechanisms followed by these enzymes (Schneider et al., EMBO J 12:2609-2615, 1993). Acid phosphatases are also found in nonmammalian species such as bacteria, fungi, parasites, and plants, and most of them share structural similarities with mammalian acid phosphatase enzymes. Acid phosphatase (EC 3.1.3.2) enzymes catalyze the hydrolysis of phosphate monoesters following the general equation. Phosphate monoester + H2O -->/<-- alcohol + phosphate. The general classification "acid phosphatase" relies only on the optimum acidic pH for the enzymatic activity in assay conditions using non-physiological substrates. These enzymes accept a wide range of substrates in vitro, ranging from small organic molecules to phosphoproteins, constituting a heterogeneous group of enzymes from the structural point of view. These structural differences account for the divergence in cofactor dependences and behavior against substrates, inhibitors, and activators. In this group only the tartrate-resistant acid phosphatase is a metallo-enzyme whereas the other members do not require metal-ion binding for their catalytic activity. In addition, tartrate-resistant acid phosphatase and erythrocytic acid phosphatase are not inhibited by L-(+)-tartrate ion while the prostatic acid phosphatase is tartrate-sensitive. This is an important difference that can be exploited in in vitro assays to differentiate between different kinds of phosphatase activity. The search for more sensitive and specific methods of detection in clinical laboratory applications led to the development of radioimmunoassays (RIA) for determination of prostatic acid phosphatase in serum. These methods permit the direct quantification of the enzyme regardless of its activity status. Therefore, an independent structural classification exists that helps to group these enzymes according to their structural features and mechanisms. Based on this we can distinguish the histidine acid phosphatases (Van Etten, Ann N Y Acad Sci 390:27-51, 1982), the low molecular weight protein tyrosine acid phosphatases and the metal-ion dependent phosphatases. A note of caution is worthwhile mentioning here. The nomenclature of acid phosphatases has not been particularly easy for those new to the subject. Unfortunately, the acronym PAP is very common in the literature about purple acid phosphatases and prostatic acid phosphatase. In addition, LPAP is the acronym chosen to refer to the lysophosphatidic acid phosphatase which is a different enzyme. It is important to bear in mind this distinction while reviewing the literature to avoid confusion.

Bone metabolism and clinical study of 44 patients with bisphosphonate-related osteonecrosis of the jaws

Osteonecrosis of the jaws is a clinical entity described and linked to treatment with bisphosphonates in 2003. Its real incidence is unknown and it could increase due to the large number of patients treated with these drugs, and its cumulative effect on the bone. State of the art knowledge regarding its etiopathogeny, clinical course and suitable treatments is limited. Objectives: To study the clinical characteristics of 44 patients with bisphosphonate-related osteonecrosis of the jaws and the state of their bone mineral metabolism: bone remodeling state, prevalence of fractures, bone mineral density study, and assessment of the different treatment strategies. Design of the Study: Observational. Information was gathered prospectively through interviews, clinical examinations, additional tests and review of medical records. Results: We studied 16 men and 28 women with a mean age of 64.7 years. Breast cancer was the most frequent underlying disease. Zoledronate was used in 82% of the cases and in the non-oncology group of patients; alendronate was the most frequently used bisphosphonate. The mean duration of the zoledronate and alendronate treatments was 25 months and 88 months respectively. The lower jaw was the most frequent location, and previous exodontias—among the triggering factors known—were the most closely linked to its onset. We found considerable osteoblastic activity in patients suffering from neoplasia, with artifacts present in their bone densitometry and a high percentage of vertebral fractures. Conclusions: According to our results, osteonecrosis of the jaws affects elderly patients. We found a direct relationship between the duration of exposure and the accumulated dose. Other relevant factors are: Poor oral and dental health, corticoids, diabetes and teeth extractions. In essence, it is a clinical diagnosis. Prevention is the best strategy to handle this clinical entity.

Key words:Alendronate, bisphosphonate, jaw, maxilla, osteonecrosis, osteoporosis, prevention, zoledronate.

Vascular effects of bisphosphonates-a systematic review

BACKGROUND

Osteoporosis and cardiovascular disease are interconnected entities with pathophysiological similarities. Bisphosphonates are therapeutic options available for resorptive bone diseases; however, experimental evidence has demonstrated a role for bisphosphonates in the inhibition of atherogenesis.

METHODS

A systematic review of the vascular effects of bisphosphonates on atherosclerosis was performed. Vascular effects were evaluated by the thickening of the intima-media of carotid arteries and calcification of the coronary and aorta arteries. Electronic databases PubMed, The Cochrane Library, and Embase from January 1980 to May 2011 were searched.

RESULTS

Of 169 potentially relevant articles, 9 clinical trials were selected. Two articles showed the benefit of the use of etidronate (-0.038 mm, P < 0.005) and alendronate (-0.025 mm, P < 0.05) on carotid artery intima-media thickening (CIMT) after one year. One article found no changes associated with the use of alendronate. The use of risedronate was associated with a reduction of plaque score on the carotid arteries (decrease of 1% at 1 year, P = 0.015). Of those studies that evaluated the effect on coronary artery calcification (CAC), the results are conflicting: one study showed no changes with use of etidronate and in another, etidronate resulted in inhibition of the process of CAC after 1 year of follow-up (-372 mm(3) in CAC score, P < 0.01). Three studies showed positive effects of etidronate on the aortic calcificaton (AC) score, showing no effect with use of ibandronate, and another showed a inhibition in the progression of the abdominal AC score with use of risendronate (P = 0.043).

CONCLUSION

Bisphosphonates seem to have an inhibitory effect on the atherosclerotic process; however, larger placebo-controlled studies are needed to better clarify this issue.

Plectranthus amboinicus attenuates inflammatory bone erosion in mice with collagen-induced arthritis by downregulation of RANKL-induced NFATc1 expression

OBJECTIVE

Plectranthus amboinicus has been known to treat inflammatory diseases or swelling symptoms. We investigated whether P. amboinicus exhibited an inhibitory effect on osteoclastogenesis in vitro and inflammatory bone erosion in collagen-induced arthritis (CIA) mice, an animal model of rheumatoid arthritis. We attempted to identify the active component of P. amboinicus involved in regulation of osteoclastogenesis.

METHODS

We treated M-CSF- and RANKL-stimulated murine bone marrow-derived macrophages (BMM) and RANKL-induced RAW264.7 cells with different concentrations of P. amboinicus or rosmarinic acid, a phytopolyphenol purified from P. amboinicus, to monitor osteoclast formation by TRAP staining. The mechanism of the inhibition was studied by biochemical analysis such as RT-PCR and immunoblotting. CIA mice were administered gavages of P. amboinicus (375 mg/kg) or placebo. Then clinical, histological, and biochemical measures were assessed to determine the effects of P. amboinicus on synovial inflammation and bone erosion by H&E staining of the inflamed joints and ELISA.

RESULTS

Rosmarinic acid strongly inhibited RANKL-induced NF-κB activation and nuclear factor of activated T cells c1 (NFATc1) nuclear translocation in BMM, and also inhibited RANKL-induced formation of TRAP-positive multinucleated cells. A pit formation assay and the CIA animal model showed that P. amboinicus significantly inhibited the bone-resorbing activity of mature osteoclasts.

CONCLUSION

We postulated that rosmarinic acid conferred the inhibitory activity on P. amboinicus for inhibition of osteoclastogenesis via downregulation of RANKL-induced NFATc1 expression. Our results indicated the possibility of P. amboinicus as a new remedy against inflammatory bone destruction.

Does alendronate disturb the healing process of posterior lumbar interbody fusion? A prospective randomized trial

Object

Bisphosphonate medications are widely used for the treatment of osteoporosis, but they might disturb the healing process of spinal fusion. The object of this prospective randomized controlled study was to evaluate the effect of bisphosphonate medication on spinal fusion through radiographic, clinical, and biological assessments.

Methods

A total of 40 patients with osteoporosis who were candidates for single-level posterior lumbar interbody fusion were randomly assigned to the alendronate group (alendronate sodium 35 mg/week) or the control group (vitamin D, alfacalcidol 1 μg/day). Pedicle screw fixation and carbon polyetheretherketone cages were used for all the patients. Bone graft material was prepared as a mixture of local bone and β-tricalcium phosphate in a ratio of 2:1. Functional radiography and CT scans were used to evaluate fusion status and cage subsidence. The incidence of vertebral compression fractures (VCFs) occurring after surgery (subsequent VCFs) was assessed by means of MR imaging. Bridging bone formation was graded into 3 categories: Grade A (bridging bone through bilateral cages), Grade B (bridging bone through a unilateral cage), or Grade C (incomplete bony bridging). A solid fusion was defined as less than 5° of angular motion in flexion-extension radiographs and the presence of bridging bone through the cage (Grade A or B). Clinical outcome was evaluated by means of the Oswestry Disability Index. Bone metabolic markers (serum bone alkaline phosphatase, serum and urine Type I collagen cross-linked N-telopeptides) were measured to investigate the biological effects of alendronate on spinal fusion.

Results

Bridging bone formation (Grade A or B) was more frequently observed in the alendronate group at all postoperative assessment periods. At 1-year postoperative follow-up, a solid fusion was achieved in 95% of the patients in the alendronate group and 65% of those in the control group. Cage subsidence (> 2 mm) was observed in 5% of the alendronate group and 29% of the control group. No vertebral fractures were observed in the alendronate group, whereas 24% of patients in the control group showed subsequent VCFs. There was no statistically significant between-groups difference in clinical outcomes, but poor clinical results in the control group were associated with pseudarthrosis and subsequent VCFs. Biochemical analysis of bone turnover demonstrated that alendronate inhibited bone resorption from the early phase of the fusion process and also suppressed bone formation after 6 months postoperatively.

Conclusions

Favorable mechanical circumstances provided by alendronate overcame its detrimental biological effect on the healing process of spinal fusion. The authors recommend that osteoporosis patients undergoing spinal fusion take bisphosphonates throughout the postoperative period.

Icariin inhibits osteoclast differentiation and bone resorption by suppression of MAPKs/NF-κB regulated HIF-1α and PGE(2) synthesis

Icariin has been reported to enhance bone healing and treat osteoporosis. In this study, we examined the detail molecular mechanisms of icariin on lipopolysaccharide (LPS)-induced osteolysis. Our hypothesis is that icariin can inhibit osteoclast differentiation and bone resorption by suppressing MAPKs/NF-κB regulated HIF-1α and PGE(2) synthesis. After treatment with icariin, the activity of osteoclasts differentiation maker, tatrate resistances acid phosphatease (TRAP), significantly decreased at the concentration of 10(-8)M. Icariin (10(-8)M) reduced the size of LPS-induced osteoclasts formation, and diminished their TRAP and acid phosphatease (ACP) activity without inhibition of cell viability. Icariin also inhibited LPS-induced bone resorption and interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) expression. The gene expression of osteoprotegerin (OPG) was up-regulated, while receptor activator of NF-κB ligand (RANKL) was down-regulated. Icariin also inhibited the synthesis of cyclo-oxygenase type-2 (COX-2) and prostaglandin E(2) (PGE(2)). In addition, icariin had a dominant repression effect on LPS-induced hypoxia inducible factor-1α (HIF-1α) expression of osteoclasts. On osteoclasts, icariin suppresses LPS-mediated activation of the p38 and JNK; while on the osteoblasts, icariin reduced the LPS-induced activation of ERK1/2 and I-kappa-B-alpha (IκBα), but increased the activation of p38. In conclusion, we demonstrated that icariin has an in vitro inhibitory effects on osteoclasts differentiation that can prevent inflammatory bone loss. Icariin inhibited LPS-induced osteoclastogenesis program by suppressing activation of the p38 and JNK pathway.

Amorphigenin inhibits Osteoclast differentiation by suppressing c-Fos and nuclear factor of activated T cells

Among the several rotenoids, amorphigenin is isolated from the leaves of Amopha Fruticosa and it is known that has anti-proliferative effects and anti-cnacer effects in many cell types. The main aim of this study was to investigate the effects of amorphigenin on osteoclast differentiation in vitro and on LPS treated inflammatory bone loss model in vivo. We show here that amorphigenin inhibited RANKL-induced osteoclast differentiation from bone marrow macrophages in a dose dependent manner without cellular toxicity. Anti-osteoclastogenic properties of amorphigenin were based on a down-regulation of c-fos and NFATc1. Amorphigenin markedly inhibited RANKL-induced p38 and NF-κB pathways, but other pathways were not affected. Micro-CT analysis of the femurs showed that amorphigenin protected the LPS-induced bone loss. We concluded that amorphigenin can prevent inflammation-induced bone loss. Thus we expect that amorphigenin could be a treatment option for bone erosion caused by inflammation.

Skeletal manifestations of systemic autoimmune diseases

PURPOSE OF REVIEW

There is an increased risk of osteoporotic fractures and osteonecrosis often at a young age among patients with certain systemic autoimmune diseases. The loss of bone mineral density and bone integrity seen with these diseases often cannot be explained by traditional risk factors alone. In this review, we focus on rheumatoid arthritis and systemic lupus erythematosus, two systemic autoimmune diseases in which skeletal manifestations have been well described.

RECENT FINDINGS

There is recent evidence that autoimmunity and its associated inflammation and vitamin D deficiency play key roles in the pathogenesis of adverse skeletal effects.

SUMMARY

Understanding these processes carries implications for the prevention and treatment of osteoporosis and osteonecrosis among patients with autoimmune diseases.

Discovery of novel benzopyranyl tetracycles that act as inhibitors of osteoclastogenesis induced by receptor activator of NF-κB ligand

A novel benzopyran-fused molecular framework 7ai was discovered as a specific inhibitor of RANKL-induced osteoclastogenesis using a cell-based TRAP activity assay from drug-like small-molecule libraries constructed by diversity-oriented synthesis. Its inhibitory activity was confirmed by in vitro evaluations including specific inhibition of RANKL-induced ERK phosphorylation and NF-κB transcriptional activation. 7ai can serve as a specific small-molecule modulator for mechanistic studies of RANKL-induced osteoclast differentiation as well as a potential lead for the development of antiresorptive drugs.

Osteonecrosis of jaws related to intravenous bisphosphonates: the experience of a Jordanian teaching hospital

INTRODUCTION

We describe our experience with oncology patients on a frequent dosing schedule of intravenous (i.v.) bisphosphonates at the Jordan University Hospital (JUH).

PATIENTS AND METHODS

Patients treated by i.v. bisphosphonates in the medical oncology unit at the JUH were examined for bisphosphonate-related osteonecrosis of the jaws (BRONJ). Diagnosis was made according to the guidelines of the American Association of Oral and Maxillofacial Surgeons (AAOMS) original position paper.

RESULTS

Of the 41 patients, four developed BRONJ, two in maxilla, one in mandible and one bimaxillary. Patients with BRONJ were older; mean age was 69.3 +/- 3.1 years compared to 62.8 +/- 12.5 years (P = 0.022). Dental co-morbidities were more commonly present in patients with the disease (P = 0.038). Patients who developed BRONJ were on treatment for a longer duration of time; the mean duration of treatment was 23.5 +/- 8.4 months compared to 11.9 +/- 13.4 months (P = 0.10).

CONCLUSIONS

The results of this case series demonstrated that age and poor oral health status are significant risk factors of BRONJ for oncology patients on long-term frequent dosing schedule of i.v. bisphosphonates.

Estimating the cost effectiveness of alternative drug treatments for postmenopausal osteoporosis

The burden of postmenopausal osteoporosis is substantial and is likely to grow as the baby-boom generation ages. A greater understanding of the costs and clinical benefits of alternative therapies for postmenopausal osteoporosis is needed to develop informed health policies to reduce the future burden of osteoporosis. However, much of the data needed to evaluate the cost effectiveness of alternative therapies for postmenopausal osteoporosis are not available from clinical trials. Thus, cost-effectiveness models must cope with a high degree of uncertainty. This article provides a brief summary of the methodologic issues in cost-effectiveness analyses of current osteoporosis therapies, a review of the findings in published cost-effectiveness studies, and a discussion of challenges likely to be encountered in future economic evaluations of emerging osteoporosis therapies.

Inhibition of osteoclast differentiation and bone resorption by rotenone, through down-regulation of RANKL-induced c-Fos and NFATc1 expression

Osteoclasts are responsible for bone erosion in diseases as diverse as osteoporosis, periodontitis, and rheumatoid arthritis. Natural plant-derived products have received recent attention as potential therapeutic and preventative drugs in human disease. The effect of rotenone in RANKL-induced osteoclast differentiation was examined in this study. Rotenone inhibited RANKL-mediated osteoclast differentiation in bone marrow macrophages (BMMs) in a dose-dependent manner without any evidence of cytotoxicity. The mRNA expression of c-Fos, NFATc1, TRAP, and OSCAR in RANKL-treated BMMs was inhibited by rotenone treatment. Rotenone strongly inhibited p38 and ERK phosphorylation and I-kappaB degradation in RANKL-stimulated BMMs, and did not inhibit JNK phosphorylation. Further, RANKL-induced c-Fos and NFATc1 protein expression was suppressed by rotenone. Rotenone additionally inhibited the bone resorptive activity of differentiated osteoclasts. A lipopolysaccharide (LPS)-induced bone erosion study was also performed to assess the effects of rotenone in vivo. Mice treated with rotenone demonstrated marked attenuation of bone erosion based on Micro CT and histologic analysis of femurs. These results collectively suggested that rotenone demonstrated inhibitory effects on osteoclast differentiation in vitro and suppressed inflammatory bone loss in vivo. Rotenone may therefore serve as a useful drug in the prevention of bone loss.

Effects of volatile components and ethanolic extract from Eclipta prostrata on proliferation and differentiation of primary osteoblasts

Eclipta prostrata, an aromatic plant, is known in Chinese herbal medicine for the treatment of various kidney diseases. In the present study, the volatile components were isolated from the aerial parts of this plant by hydrodistillation and analysed by GC-MS. A total of 55 compounds, which were the major part (91.7%) of the volatiles, were identified by matching mass spectra with a mass spectrum library (NIST 05.L). The main components were as follows: heptadecane (14.78%), 6,10,14-trimethyl-2-pentadecanone (12.80%), n-hexadecanoic acid (8.98%), pentadecane (8.68%), eudesma-4(14),11-diene (5.86%), phytol (3.77%), octadec-9-enoic acid (3.35%), 1,2-benzenedicarboxylic acid diisooctyl ester (2.74%), (Z,Z)-9,12-octadecadienoic acid (2.36%), (Z)-7,11-dimethyl-3-methylene-1,6,10-dodecatriene (2.08%) and (Z,Z,Z)-1,5,9,9-tetramethyl-1,4,7-cycloundecatriene (2.07%). The effects of volatile components and ethanolic extract from the aerial parts of this plant on the proliferation and differentiation of primary osteoblasts were evaluated by the MTT method and measuring the activity of alkaline phosphatase (ALP activity). Both volatile components and ethanolic extract (1 microg/mL to 100 microg/mL) significantly (p < 0.01) stimulated the proliferation and increased the ALP activity of primary osteoblasts. These results propose that E. prostrata can play an important role in osteoblastic bone formation, and may possibly lead to the development of bone-forming drugs.

Prior treatment with vitamin K(2) significantly improves the efficacy of risedronate

Prior 8-week treatment with menatetrenone, MK-4, followed by 8-week risedronate prevented the shortcomings of individual drugs and significantly increased the strength of ovariectomized ICR mouse femur compared to the ovariectomized (OVX) controls. Neither MK-4 following risedronate nor the concomitant administration may be recommended because they brought the least beneficial effect.

INTRODUCTION

The objective of this study was to determine the best combinatory administration of risedronate at 0.25 mg/kg/day (R) with vitamin K(2) at approximately 100 microg MK-4/kg/day (K) to improve strength of osteoporotic mouse bone.

METHODS

Thirteen-week-old ICR mice, ovariectomized at 9-week, were treated for 8 weeks with R, K, or R plus K (R/K), and then, either the treatment was withdrawn (WO) or switched to K or R in the case of R and K. After another 8 weeks, the mice were killed, and mechanical tests and analyses of femur properties by peripheral quantitative computed tomography, microfocus X-ray tube computed tomography, and confocal laser Raman microspectroscopy were carried out.

RESULTS

The K to R femur turned out superior in parameters tested such as material properties, bone mineral density, BMC, trabecular structure, and geometry of the cortex. The increased cross-sectional moment of inertia, which occurred after K withdrawal, was prevented by risedronate in K to R. In addition to K to R, some properties of R to WO diaphysis and K to WO epiphysis were significantly better than OVX controls.

CONCLUSION

Prior treatment with MK-4 followed by risedronate significantly increased femur strength in comparison to the OVX controls.

Pregnancy outcome following in utero exposure to bisphosphonates

BACKGROUND AND AIM

The safety of bisphosphonates in human pregnancy has not been well established. To characterize pregnancy outcome in women receiving bisphosphonates, we conducted a multi-centre, prospective cohort study with a comparison group.

METHODS

Patients were recruited through 3 teratogen information centres in Canada and South Korea. We followed 21 women exposed to bisphosphonates during or <3 months before pregnancy, and 21 matched-comparison group women without exposure to known teratogens. Pregnancy/neonatal outcome data were collected by interview. The primary endpoint was neonatal outcome including major birth defects. The secondary endpoints included other pregnancy outcomes such as spontaneous abortions.

RESULTS

Indication of the therapy was osteoporosis in all patients. There was no difference in the maternal demographics between the 2 groups. In the bisphosphonate group, there were 18 live births, 2 spontaneous abortions and 1 therapeutic abortion, which were not significantly different from the comparison group. The mean gestational age (mean+/-SD) of the bisphosphonate group was 38.7+/-1.9 weeks (comparison group: 39.3+/-1.9 weeks; P=0.42), and the mean birth weight was 3.1+/-0.3 kg (comparison group: 3.3+/-0.5 kg; P=0.11). In the bisphosphonate group, there was a child diagnosed with Apert syndrome, an autosomal dominant acrocephalosyndactyly, with a fibroblast growth factor 2 mutation.

CONCLUSION

Coupled with existing data in the literature, our findings suggest that preconceptional and first-trimester use of bisphosphonates may not pose substantial fetal risks.

Osteonecrosis and bisphosphonates in oral and maxillofacial surgery

Bisphosphonates are a class of compounds approved for the treatment of multiple myeloma, hypercalcemia of malignancy, osteolytic lesions of metastatic disease, Paget's disease, and most commonly, osteoporosis. Recently, these drugs have been associated with a new clinical entity, bisphosphonate related osteonecrosis (BRON) which is characterized by jaw necrosis that typically presents following dentoalveolar surgery. The pathogenesis for this complication appears to related to bisphosphonate mediated inhibition of osteoclast function and normal bone remodeling. This complication can have a significant impact on the quality of life for those patients with advanced stages of necrosis.

The osteoporosis needs of patients with wrist fracture

OBJECTIVES

To provide information for practitioners regarding the osteoporosis (OP)-related needs of patients who present with low-trauma wrist fractures and are at high risk of subsequent hip fracture.

DESIGN

Prospective protocol, retrospective analysis.

SETTING

Large urban teaching hospital, regional trauma center.

PATIENTS

All outpatients (women > or =40 years; men > or =50 years) who sustained fragility fractures of the wrist between December 1, 2002 and June 30, 2005.

INTERVENTION

Patients were evaluated by a coordinator and recruited to an OP program for education, diagnosis, and treatment. Patient demographic data were collected. A baseline questionnaire included fracture and OP risk history, sociodemographics, Osteoporosis Health Beliefs Scale, and Osteoporosis Self-Efficacy Scale.

MAIN OUTCOME MEASURES

Fracture history, OP risk factors, attitudes, and beliefs.

RESULTS

Of 339 patients with wrist fractures, 286 had fragility fractures (mean age 64.8 years; 82% female) and met the age criteria. Seventeen percent of men and 36% of women with fragility wrist fractures had been previously diagnosed with OP or osteopenia; nearly all of them had been prescribed supplements, and two thirds had received aminobisphosphonate treatment for OP. Half of the patients had one or more risk factors for OP. Most patients were aware of OP, but few felt their fracture could result from OP. Bone densitometry completed on 55 patients in the first year indicated OP or osteopenia in 43 of 55 patients. Patients' health beliefs underestimated the seriousness of OP. Every patient with a fragility fracture of the wrist should understand that: (1) their fracture may be related to OP; (2) by having a fragility fracture, they are at higher risk for hip fracture; and (3) preventive treatment is effective and safe. Information should be partly gender specific. Patients who believe that weak bones didn't cause their fracture require additional attention to motivate them to undergo special treatment.

CONCLUSIONS

Intervention by the orthopaedic team to address potential underlying OP in patients with low-trauma wrist fractures should include directed patient education, testing, treatment with supplements and pharmacotherapy where indicated, and referral as needed.

A coordinator program in post-fracture osteoporosis management improves outcomes and saves costs

BACKGROUND

The orthopaedic unit at a university teaching hospital hired an osteoporosis coordinator to identify patients with a fragility fracture and to coordinate their education, assessment, referral, and treatment of underlying osteoporosis. We report the results of an analysis of the cost-effectiveness of the use of a coordinator (in comparison with the use of no coordinator) in avoiding future costs of subsequent hip fracture.

METHODS

A one-year decision-analysis model was developed. The health outcome was subsequent hip fracture; only direct hospital costs were considered. With use of patient-level data from a previously described coordinator program and data from the literature, the expected annual incidence of subsequent hip fracture was calculated, on the basis of the type of index fracture (wrist, hip, humerus, other), attribution to osteoporosis, age, and gender. The rate of patient referral, the initiation of osteoporosis treatment, and adherence to therapy were modeled to modify the expected incidence of future hip fracture in the presence of a coordinator (with use of data from the program) and in the absence of a coordinator (with use of data from the literature). Sensitivity analysis modeling techniques were used to assess variable uncertainty and to evaluate coordinator cost-effectiveness.

RESULTS

Deterministic cost-effectiveness analysis showed that a tertiary care center that hired an osteoporosis coordinator who manages 500 patients with fragility fractures annually could reduce the number of subsequent hip fractures from thirty-four to thirty-one in the first year, with a net hospital cost savings of C$48,950 (Canadian dollars in year-2004 values), with use of conservative assumptions. Probabilistic sensitivity analysis indicated a 90% probability that hiring a coordinator costs less than C$25,000 per hip fracture avoided. Hiring a coordinator is a cost-saving measure even when the coordinator manages as few as 350 patients annually. Greater savings are anticipated after the first year and when additional costs such as rehabilitation and dependency costs are considered.

CONCLUSIONS

Employment of an osteoporosis coordinator to manage outpatients and inpatients who have fragility fractures is predicted to reduce the incidence of future hip fractures and to save money (a dominant strategy). A probabilistic sensitivity analysis showed a high probability of cost-effectiveness of this intervention from the hospital cost perspective.

Effects of Restricted Calcium Intake on Bone and Maxillofacial Growth

Objective: To investigate the effects of a low calcium diet on maxillofacial development by evaluating Bone Mineral Content (BMC) in the lower alveolar bones, femurs, and tibias and by performing cephalometry on growing rats.

Materials and Methods: Thirty 5-week-old male Wistar rats were randomly divided into 3 groups; the control group (n = 10) was given standard diet for 6 weeks, the low calcium/standard diet group (n = 10) was given a calcium-restricted diet for the first 4 weeks, and then a standard diet for the following 2 weeks, and the low calcium diet group (n = 10) was given the calcium-restricted diet for 6 weeks. After the rats were euthanized, heads and legs were fixed and cephalometry was performed. Next, mandibles, femurs and tibias were digitally photographed and the BMC was evaluated using our newly developed software.

Results: The BMC was decreased in all of the bone samples from the two groups that received restricted calcium. In the low calcium/standard diet group, the BMC recovered the most in the tibias and least in the lower alveolar bones. Development of the mandibles in the anterior-posterior direction was accelerated, while that in the superior-inferior direction was inhibited in those rats.

Conclusion: The BMC reduction following calcium deficiency in the lower alveolar bone hardly recovers, so prevention is important. Development of the mandible in a superior-inferior direction is inhibited while that in an anterior-posterior direction is accelerated due to a calcium-restricted diet.

Improvement of bone disease by imiglucerase (Cerezyme) therapy in patients with skeletal manifestations of type 1 Gaucher disease: results of a 48-month longitudinal cohort study

Sims KB, Pastores GM, Weinreb NJ, Barranger J, Rosenbloom BE, Packman S, Kaplan P, Mankin H, Xavier R, Angell J, Fitzpatrick MA, Rosenthal D. Improvement of bone disease by imiglucerase (Cerezyme) therapy in patients with skeletal manifestations of type 1 Gaucher disease: results of a 48-month longitudinal cohort study. Clin Genet 2008: 73: 430–440. © Blackwell Munksgaard, 2008

Progressive skeletal disease accounts for some of the most debilitating complications of type 1 Gaucher disease. In this 48-month, prospective, non-randomized, open-label study of the effect of enzyme replacement therapy on bone response, 33 imiglucerase-naïve patients (median age 43 years with one or more skeletal manifestations such as osteopenia, history of bone crisis, or other documented bone pathology) received imiglucerase 60 U/kg/2 weeks. Substantial improvements were observed in bone pain (BP), bone crises (BC), and bone mineral density (BMD). Improvements in BP were observed at 3 months (p < 0.001 vs baseline) and continued progressively throughout the study, with 39% of patients reporting pain at 48 months vs 73% at baseline. Eleven of the 13 patients with a pre-treatment history of BC had no recurrences. Biochemical markers for bone formation increased; markers for bone resorption decreased. Steady improvement of spine and femoral neck BMD, measured using dual-energy X-ray absorptiometry was noted. Mean Z score for spine increased from −0.72 ± 1.302 at baseline to near-normal levels (−0.09 ± 1.503) by month 48 (p = 0.042) and for femoral neck from −0.59 ± 1.352 to −0.17 ± 1.206 (p = 0.035) at month 36. This increase was sustained at 48 months. With imiglucerase treatment, patients should anticipate resolution of BC, rapid improvement in BP, increases in BMD, and decreased skeletal complications.

Characteristics and mechanical properties of acrylolpamidronate-treated strontium containing bioactive bone cement

The aim of the present study was to determine the influence of surface treatment on the mechanical properties of strontium-containing hydroxyapatite (Sr-HA) bioactive bone cement. Previously we developed an injectable bioactive cement (SrHAC) system composed of Sr-HA powders and bisphenol A diglycidylether dimethacrylate (Bis-GMA). In this study, the Sr-HA powder was subjected to surface treatment using acrylolpamidronate, a bisphosphonate derivative, which has a polymerizable group, to improve the interface between inorganic filler and organic matrix by binding Sr-HA and copolymerizing into the matrix. After surface treatment, the compression strength, bending strength, and stiffness of the resulting composites were defined by using a material testing machine (MTS) according to ISO 5833. The fracture surface of the bone cement specimen was observed with a scanning electron microscope. Invitro cytotoxicity of surface-treated SrHAC was also studied using a tetrazolium-based cell viability assay (MTS/pms) on human osteoblast-like cells, the SaOS-2 cell line. Cells were seeded at a density of 10(4)/mL and allowed to grow in an incubator for 48 h at 37 degrees C. Results indicated that after surface treatment, the compression strength and stiffness significantly improved by 22.68 and 14.51%, respectively. The bending strength and stiffness of the bioactive bone cement also showed 19.06 and 8.91% improvements via three-point bending test. The fracture surface micromorphology after compression and bending revealed that the bonding between the resin to surface-treated filler considerably improved. The cell viability indicated that the treated particles were nontoxic and did not inhibit cell growth. This study demonstrated a new surface chemistry route to enhance the covalent bonds between inorganic fillers and polymer matrix for improving the mechanical properties of bone cement. This method not only improves the overall mechanical performance but also increases osteoblastic activity.