The crisis of inadequate treatment in osteoporosis

Genetic Prediction of Osteoporosis by Anti-Müllerian Hormone Levels and Reproductive Factors in Women: A Mendelian Randomization Study

Previous observational studies have suggested that anti-Müllerian hormone (AMH) and reproductive factors are linked to reduced bone mineral density (BMD) and an increased risk of osteoporosis (OP) in women. However, related studies are limited, and these traditional observational studies may be subject to residual confounders and reverse causation, while also lacking a more comprehensive observation of various reproductive factors. Univariate and multivariate two-sample Mendelian randomization analyses were conducted to determine the causal associations of AMH levels and six reproductive factors with BMD and OP, using the random-effects inverse-variance weighted method. Heterogeneity was assessed using Cochran's Q-statistic, and sensitivity analyses were performed to identify causal correlations. Age at menarche (AAM) was negatively associated with total body BMD (TB-BMD) in females aged 45-60 and over 60 years, as well as with heel bone mineral density (eBMD). Conversely, age at natural menopause (ANM) was positively associated with TB-BMD in the same age ranges and with eBMD. ANM was only causally associated with self-reported OP and showed no significant correlation with definitively diagnosed OP. Neither AMH level nor other reproductive factors were significantly associated with a genetic predisposition to BMD at any age and OP. Later AAM and earlier ANM are significantly genetically causally associated with decreased BMD but not with OP. AMH levels, length of menstrual cycle, age at first birth, age at last birth, and number of live births, in terms of genetic backgrounds, are not causally related to BMD or OP.

Outcomes following hip fracture surgery in adults with schizophrenia in Ontario, Canada: A 10-year population-based retrospective cohort study

OBJECTIVE

To understand immediate and long-term outcomes following hip fracture surgery in adults with schizophrenia.

METHODS

Retrospective population-based cohort study leveraging health administrative databases from Ontario, Canada. Individuals aged 40-105 years with hip fracture surgery between April 1, 2009 and March 31, 2019 were included. Schizophrenia was ascertained using a validated algorithm. Outcomes were: 30-day mortality; 30-day readmission; 1-year survival; and subsequent hip fracture within 2 years. Analyses incorporated Generalized Estimating Equation models, Kaplan-Meier curves, and Fine-Gray competing risk models.

RESULTS

In this cohort study of 98,126 surgically managed hip fracture patients, the median [IQR] age was 83[75-89] years, 69.2% were women, and 3700(3.8%) had schizophrenia. In Fine-Gray models, schizophrenia was associated with subsequent hip fracture (sdRH, 1.29; 95% CI, 1.09-1.53), with male patients with schizophrenia sustaining a refracture 50 days earlier. In age- and sex-adjusted GEE models, schizophrenia was associated with 30-day mortality (OR, 1.31; 95% CI, 1.12-1.54) and readmissions (OR, 1.40; 95% CI, 1.25-1.56). Kaplan-Meier survival curves suggested that patients with schizophrenia were less likely to be alive at 1-year.

CONCLUSIONS

Study highlights the susceptibility of hip fracture patients with schizophrenia to worse outcomes, including refracture, with implications for understanding modifiable processes of care to optimize their recovery.

Global pattern, trend, and cross-country inequality of early musculoskeletal disorders from 1990 to 2019, with projection from 2020 to 2050

BACKGROUND

This study aims to estimate the burden, trends, forecasts, and disparities of early musculoskeletal (MSK) disorders among individuals ages 15 to 39 years.

METHODS

The global prevalence, years lived with disabilities (YLDs), disability-adjusted life years (DALYs), projection, and inequality were estimated for early MSK diseases, including rheumatoid arthritis (RA), osteoarthritis (OA), low back pain (LBP), neck pain (NP), gout, and other MSK diseases (OMSKDs).

FINDINGS

More adolescents and young adults were expected to develop MSK disorders by 2050. Across five age groups, the rates of prevalence, YLDs, and DALYs for RA, NP, LBP, gout, and OMSKDs sharply increased from ages 15-19 to 35-39; however, these were negligible for OA before age 30 but increased notably at ages 30-34, rising at least 6-fold by 35-39. The disease burden of gout, LBP, and OA attributable to high BMI and gout attributable to kidney dysfunction increased, while the contribution of smoking to LBP and RA and occupational ergonomic factors to LBP decreased. Between 1990 and 2019, the slope index of inequality increased for six MSK disorders, and the relative concentration index increased for gout, NP, OA, and OMSKDs but decreased for LBP and RA.

CONCLUSIONS

Multilevel interventions should be initiated to prevent disease burden related to RA, NP, LBP, gout, and OMSKDs among individuals ages 15-19 and to OA among individuals ages 30-34 to tightly control high BMI and kidney dysfunction.

FUNDING

The Global Burden of Disease study is funded by the Bill and Melinda Gates Foundation. The project is funded by the Scientific Research Fund of Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital (2022QN38).

Osteoporosis management in adults with schizophrenia following index hip fracture event: a 10-year population-based retrospective cohort study, Ontario, Canada

Little is known about the incidence of osteoporosis testing and treatment in individuals with schizophrenia, who may be more likely to fracture. Using competing risk models, we found that schizophrenia was associated with lower incidence of testing or treatment. Implications are for understanding barriers and solutions for this disadvantaged group.

PURPOSE

Evidence suggests that individuals with schizophrenia may be more likely to experience hip fractures than the general population; however, little is known about osteoporosis management in this disadvantaged subpopulation. Our study objective was to compare bone mineral density (BMD) testing and pharmacologic treatment in hip fracture patients with versus without schizophrenia.

METHODS

This was a retrospective population-based cohort study leveraging health administrative databases, and individuals aged 66-105 years with hip fracture between fiscal years 2009 and 2018 in Ontario, Canada. Schizophrenia was ascertained using a validated algorithm. The outcome was a composite measure of (1) pharmacologic prescription for osteoporosis; or (2) a BMD test. Inferential analyses were conducted using Fine-Gray subdistribution hazard regression, with mortality as the competing event.

RESULTS

A total of 52,722 individuals aged 66 to 105 years who sustained an index hip fracture in Ontario during the study period were identified, of whom 1890 (3.6%) had schizophrenia. Hip fracture patients with vs without schizophrenia were more likely to be long-term care residents (44.3% vs. 18.1%; standardized difference, 0.59), frail (62.5% vs. 36.5%; standardized difference, 0.54) and without a primary care provider (9.2% vs. 4.8%; standardized difference, 0.18). In Fine-Gray models, schizophrenia was associated with a lower incidence of testing or treatment (0.795 (0.721, 0.877)).

CONCLUSIONS

In this population-based retrospective cohort study, a schizophrenia diagnosis among hip fracture patients was associated with a lower incidence of testing or treatment, after accounting for mortality, and several enabling and predisposing factors. Further research is required to investigate barriers to osteoporosis management in this disadvantaged population.

Inflammatory Processes Affecting Bone Health and Repair

PURPOSE OF REVIEW

The purpose of this article is to review the current understanding of inflammatory processes on bone, including direct impacts of inflammatory factors on bone cells, the effect of senescence on inflamed bone, and the critical role of inflammation in bone pain and healing.

RECENT FINDINGS

Advances in osteoimmunology have provided new perspectives on inflammatory bone loss in recent years. Characterization of so-called inflammatory osteoclasts has revealed insights into physiological and pathological bone loss. The identification of inflammation-associated senescent markers in bone cells indicates that therapies that reduce senescent cell burden may reverse bone loss caused by inflammatory processes. Finally, novel studies have refined the role of inflammation in bone healing, including cross talk between nerves and bone cells. Except for the initial stages of fracture healing, inflammation has predominately negative effects on bone and increases fracture risk. Eliminating senescent cells, priming the osteo-immune axis in bone cells, and alleviating pro-inflammatory cytokine burden may ameliorate the negative effects of inflammation on bone.

Chinese medicine Gushukang capsule for treating primary osteoporosis: a systematic review and meta-analysis

OBJECTIVE

To systematically evaluate the efficacy and safety of Gushukang (GSK) capsules in the treatment of primary osteoporosis.

METHODS

Randomized controlled trials related to the treatment of primary osteoporosis were collected through online retrieval of the China National Knowledge Infrastructure (CNKI), Wanfang database, Chinese Biomedical Literature Database (Sino-Med), VIP, US National Library of Medicine (PubMed), Web of Science and Cochrane library. The literature was searched from January 1, 2000, to March 17, 2022. The risk bias and quality of the trials included in the meta-analysis were evaluated with the Cochrane Collaboration's risk assessment tool. The effect size was expressed as risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs).

RESULTS

A total of 24 randomized controlled clinical trials (RCTs) were incorporated into this systematic review. The 2363 patients were all primary osteoporosis patients, of whom 1197 were in the observation group and 1166 were in the control group. GSK capsule group was superior to conventional medication group in improving beta type I collagen carboxy-terminal peptide (β-CTX) (MD - 0.28, 95% CI [- 0.31, - 0.25]), while in improving prepeptide of type I procollagen (PINP), conventional medications group was superior to GSK capsule group (MD - 1.37, 95% CI [- 1.92, - 0.82]), and there were no significant differences between the two groups in overall efficacy (OE) (OR 1.62, 95% CI [0.89, 2.98]), increase of bone mineral density (BMD) (lumbar spine: MD - 0.02, 95% CI [- 0.08, 0.04]; femoral neck: MD - 0.01, 95% CI [- 0.07, 0.05]; hip: MD 0.01, 95% CI [- 0.02, 0.02]), enhancement of alkaline phosphatase (ALP) (MD - 1.37, 95% CI [- 13.29, 10.55]), serum calcium (S-Ca) (MD 0.02, 95% CI [- 0.13, 0.17]), bone glutamyl protein (BGP) (MD 3.75, 95% CI [- 12.26, 19.76]), safety (OR 0.37, 95% CI [0.07, 2.02]) and pain relief (MD 0.32, 95% CI [- 0.59, 1.22]). GSK capsule combined with conventional medications group was superior to conventional medications group in improvement of OE (OR 3.19, 95% CI [2.20, 4.63]), BMD (lumbar spine (MD 0.06, 95% CI [0.02, 0.10]), femoral neck (MD 0.08, 95% CI [0.03, 0.13]), hip (MD 0.14, 95% CI [0.08, 0.21]) and other parts (MD 0.04, 95% CI [0.03, 0.05]), ALP (MD - 5.56, 95% CI [- 10.08, - 1.04]), β-CTX (MD - 0.15, 95% CI [- 0.18, - 0.12]) and pain relief (MD - 1.25, 95% CI [- 1.83, - 0.68]), but there was no difference in S-Ca (MD 0.02, 95% CI [- 0.13, 0.17]), BGP (MD 1.30, 95% CI [- 0.29, 2.89]), PINP (MD 1.30, 95% CI [- 0.29, 2.89]), serum phosphorus (S-P) (MD 0.01, 95% CI [- 0.09, 0.12]) and safety (OR 0.71, 95% CI [0.38, 1.35]).

CONCLUSION

GSK capsules can effectively treat primary osteoporosis, and when combined with conventional medications, the drug significantly increased bone mineral density, relieved pain and improved bone metabolism-related indicators in primary osteoporosis patients with better efficacy. However, due to the inclusion of Chinese literature and possible publication bias, the reliability of conclusions still requires more high-quality RCTs to enhance.

Drug Delivery and Therapy Strategies for Osteoporosis Intervention

With the advent of the aging society, osteoporosis (OP) risk increases yearly. Currently, the clinical usage of anti-OP drugs is challenged by recurrent side effects and poor patient compliance, regardless of oral, intravenous, or subcutaneous administration. Properly using a drug delivery system or formulation strategy can achieve targeted drug delivery to the bone, diminish side effects, improve bioavailability, and prolong the in vivo residence time, thus effectively curing osteoporosis. This review expounds on the pathogenesis of OP and the clinical medicaments used for OP intervention, proposes the design approach for anti-OP drug delivery, emphatically discusses emerging novel anti-OP drug delivery systems, and enumerates anti-OP preparations under clinical investigation. Our findings may contribute to engineering anti-OP drug delivery and OP-targeting therapy.

Quality improvement initiative: implementing routine vertebral fracture assessments into an Australian Fracture Liaison Service

Osteoporosis is a global health concern and a major contributor to worldwide mortality rates. Vertebral fractures due to osteoporosis are common and often undetected. Since vertebral fractures are often missed, evidence and guidelines suggest that vertebral fracture assessment (VFA) may optimise current approaches to bone density tests. We aimed to integrate VFA into an Australian Fracture Liaison Service (FLS) and measure the impact it had on osteoporosis treatment initiation.A retrospective case note review was undertaken to determine the number of clinic patients receiving VFA before the change in practice. Proctor's seven domains of implementation strategy were used to facilitate quality improvement outcomes.The percentage of eligible patients receiving a routine VFA at the FLS imaging centre increased from 0% to 90%. The remaining 10% of patients did not receive a scan due to the patient not being able to assume the correct position, skilled staff being unavailable to perform the scan, or the patient declining. Post implementation, almost half (41%) of patients who underwent a VFA displayed abnormalities and 16 (4%) of these recorded a normal bone measure density score but abnormal VFA. Despite the successful adoption of the new screening protocol, there was no statistically significant increase in treatment initiation rates for patients with normal bone mass density scores.The FLS successfully integrated routine VFA into the osteoporosis care pathway. However, the introduction of VFA did not significantly increase treatment initiation. It may be more effective to offer VFAs to a proportion of patients based on a tailored approach rather than offering them routinely to all patients who access the FLS.

'Skeletal Age' for mapping the impact of fracture on mortality

Background

Fragility fracture is associated with an increased risk of mortality, but mortality is not part of doctor-patient communication. Here, we introduce a new concept called 'Skeletal Age' as the age of an individual's skeleton resulting from a fragility fracture to convey the combined risk of fracture and fracture-associated mortality for an individual.

Methods

We used the Danish National Hospital Discharge Register which includes the whole-country data of 1,667,339 adults in Denmark born on or before January 1, 1950, who were followed up to December 31, 2016 for incident low-trauma fracture and mortality. Skeletal age is defined as the sum of chronological age and the number of years of life lost (YLL) associated with a fracture. Cox's proportional hazards model was employed to determine the hazard of mortality associated with a specific fracture for a given risk profile, and the hazard was then transformed into YLL using the Gompertz law of mortality.

Results

During the median follow-up period of 16 years, there had been 307,870 fractures and 122,744 post-fracture deaths. A fracture was associated with between 1 and 7 years of life lost, with the loss being greater in men than women. Hip fractures incurred the greatest loss of life years. For instance, a 60-year-old individual with a hip fracture is estimated to have a skeletal age of 66 for men and 65 for women. Skeletal Age was estimated for each age and fracture site stratified by gender.

Conclusions

We propose 'Skeletal Age' as a new metric to assess the impact of a fragility fracture on an individual's life expectancy. This approach will enhance doctor-patient risk communication about the risks associated with osteoporosis.

Funding

National Health and Medical Research Council in Australia and Amgen Competitive Grant Program 2019.

Improved CT-based Osteoporosis Assessment with a Fully Automated Deep Learning Tool

Purpose

To develop, test, and validate a deep learning (DL) tool that improves upon a previous feature-based CT image processing bone mineral density (BMD) algorithm and compare it against the manual reference standard.

Materials and Methods

This single-center, retrospective, Health Insurance Portability and Accountability Act-compliant study included manual L1 trabecular Hounsfield unit measurements from abdominal CT scans in 11 035 patients (mean age, 58 years ± 12 [SD]; 6311 women) as the reference standard. Automated level selection and L1 trabecular region of interest (ROI) placement were then performed in this CT cohort with both a previously validated feature-based image processing tool and a new DL tool. Overall technical success rates and agreement with the manual reference standard were assessed.

Results

The overall success rate of the DL tool in this heterogeneous patient cohort was significantly higher than that of the older image processing BMD algorithm (99.3% vs 89.4%, P < .001). Using this DL tool, the closest median Hounsfield unit values for single-, three-, and seven-slice vertebral ROIs were within 5% of the manual reference standard Hounsfield unit values in 35.1%, 56.9%, and 85.8% of scans; within 10% in 56.6%, 75.6%, and 92.9% of scans; and within 25% in 76.5%, 89.3%, and 97.1% of scans, respectively. Trade-offs in sensitivity and specificity for osteoporosis assessment were observed from the single-slice approach (sensitivity, 39.4%; specificity, 98.3%) to the minimum value of the multislice approach (for seven contiguous slices; sensitivity, 71.3% and specificity, 94.6%).

Conclusion

The new DL BMD tool demonstrated a higher success rate than the older feature-based image processing tool, and its outputs can be targeted for higher specificity or sensitivity for osteoporosis assessment.Keywords: CT, CT-Quantitative, Abdomen/GI, Skeletal-Axial, Spine, Deep Learning, Machine Learning Supplemental material is available for this article. © RSNA, 2022.

Trends in osteoporosis care patterns during the COVID-19 pandemic in Alberta, Canada

PURPOSE/INTRODUCTION

The objective of this study was to describe osteoporosis-related care patterns during the coronavirus disease 2019 (COVID-19) pandemic in Alberta, Canada, relative to the 3-year preceding.

METHODS

A repeated cross-sectional study design encompassing 3-month periods of continuous administrative health data between March 15, 2017, and September 14, 2020, described osteoporosis-related healthcare resource utilization (HCRU) and treatment patterns. Outcomes included patients with osteoporosis-related healthcare encounters, physician visits, diagnostic and laboratory test volumes, and treatment initiations and disruptions. The percent change between outcomes was calculated, averaged across the control periods (2017-2019), relative to the COVID-19 periods (2020).

RESULTS

Relative to the average control March to June period, all HCRU declined during the corresponding COVID-19 period. There was a reduction of 14% in patients with osteoporosis healthcare encounters, 13% in general practitioner visits, 9% in specialist practitioner visits, 47% in bone mineral density tests, and 13% in vitamin D tests. Treatment initiations declined 43%, 26%, and 35% for oral bisphosphonates, intravenous bisphosphonates, and denosumab, respectively. Slight increases were observed in the proportion of patients with treatment disruptions. In the subsequent June to September period, HCRU either returned to or surpassed pre-pandemic levels, when including telehealth visits accounting for 33-45% of healthcare encounters during the COVID periods. Oral bisphosphonate treatment initiations remained lower than pre-pandemic levels.

CONCLUSIONS

This study demonstrates the COVID-19 pandemic and corresponding public health lockdowns further heightened the "crisis" around the known gap in osteoporosis care and altered the provision of care (e.g., use of telehealth and initiation of treatment). Osteoporosis has a known substantial care and management disparity, which has been classified as a crisis. The COVID-19 pandemic created additional burden on osteoporosis patient care with healthcare encounters, physician visits, diagnostic and laboratory tests, and treatment initiations all declining during the initial pandemic period, relative to previous years.

Effect of sarcopenia and poor balance on vertebral spinal osteoporotic fracture in female rheumatoid arthritis

This study investigated the effect of poor balance and sarcopenia on vertebral spinal osteoporotic fracture (VOPF) in female rheumatoid arthritic (RA) patients. A total of 195 female RA and 126 normal subjects were enrolled, and the correlations between sarcopenia, poor balance and VOPF were analyzed. Furthermore, we explored the relationships between sarcopenia or poor balance with disease related indexes of female RA. Binary logistic regression analyses were performed to identify potential risk factors for VOPF in female RA. We found that female RA had an increased risk of sarcopenia, poor balance (Berg balance scale, BBS ≤ 40) and VOPF than controls (P < 0.0001). Female RA with VOPF were more likely to have poor balance and sarcopenia than those without VOPF (P < 0.0001-0.05). Meanwhile, female RA with sarcopenia and poor balance often had higher disease activity, more serious joint damage and worse joint function (P < 0.05) compared with those without sarcopenia and poor balance. Binary logistic regression analysis (LR backwald) revealed that age (OR = 1.112, 95% CI 1.065-1.160, P < 0.0001), OP (OR = 10.137, 95% CI 4.224-24.330, P < 0.0001) and GCs usage (OR = 3.532, 95% CI 1.427-8.741, P = 0.006) were risk factors, while SMI (OR = 0.386, 95% CI 0.243-0.614, P < 0.0001) and BBS (OR = 0.952, 95% CI 0.929-0.976, P < 0.0001) were protective factors for VOPF in female RA. Hence, sarcopenia and poor balance are associated with a higher risk for VOPF and are closely related to disease activity and joint structure damage of female RA.

Association between Anti-Osteoporotic Drugs and Risk of Acute Kidney Injury: A Cross-Sectional Study Using Disproportional Analysis and a Pharmacovigilance Database

The number of fractures related to osteoporosis is expected to increase. Therefore, clarifying the risk of acute kidney injury (AKI) associated with each type of anti-osteoporotic drug may avoid discontinuation of osteoporosis pharmacotherapy due to onset of AKI. This cross-sectional study using disproportional analysis and a pharmacovigilance database assessed the risk of AKI with various anti-osteoporotic drugs by analyzing data entered into the US Food and Drug Administration's Adverse Event Reporting System (FAERS) from April 2014 to March 2021 and the Medical Data Vision (MDV) database in Japan in November 2021. All anti-osteoporotic drugs were investigated, including bisphosphonates, selective estrogen receptor modulators, denosumab, romosozumab, abaloparatide, and teriparatide. In the analysis of FAERS data, disproportionality for decreasing AKI was observed for oral ibandronate [reporting odds ratios (ROR) 0.22, 95% confidence interval (CI) 0.09-0.45, P < 0.01], bazedoxifene (ROR 0.26, 95% CI 0.05-0.77, P = 0.01), and intravenous ibandronate (ROR 0.39, 95% CI 0.14-0.86, P = 0.01). In the analysis of the MDV data, the incidence of AKI was lower in patients taking intravenous ibandronate [odds ratio (OR) 0.22, 95% CI 0.06-0.89, P = 0.03], and the incidence of AKI was higher in patients taking oral alendronate (OR 2.40, 95% CI 2.08-2.77, P < 0.01). Risk of AKI may differ even among oral anti-osteoporotic drugs, and the evidence of this association should be assessed further in future drug safety studies. This article is protected by copyright. All rights reserved.

Finite Element Analysis of a New Type of Spinal Protection Device for the Prevention and Treatment of Osteoporotic Vertebral Compression Fractures

Objective

To study the effectiveness of a new spinal protection device for preventing and treating osteoporotic vertebral compression fractures (OVCFs) by finite element analysis (FEA).

Methods

One healthy volunteer and one patient with 1‐segment lumbar vertebral compression fractures were included in this experimental study. The DICOM files of two different lumbar spiral computed tomography (CT) scans were converted into STL files, and 3D finite element models of the lumbar spine were generated for normal and L1 vertebral fracture spines. A new type of spinal protection device was applied to reduce the stress on the anterior vertebral edge and direct the center of gravity posteriorly. The stress distribution characteristics of different finite element models of the lumbar spine were analyzed, revealing the characteristics of the stress distributed along the spine under the action of the new spinal protection device.

Results

Under normal conditions, the stress was mainly distributed in the middle and posterior columns of the spine. When the anterior border of the L1 vertebral body was fractured and collapsed, the stress distribution shifted toward the anterior column due to the center of gravity being directed forward. According to finite element analysis of the spine with the new protection device, the stress in the middle and posterior columns tended to increase, and that in the anterior column decreased. After the new type of spinal fixation device was applied, the stress at the L1 and L2 vertebral endplates decreased to a certain extent, especially that at the L1 vertebral body. The maximum stress on the L1 vertebral body decreased by 20% after the auxiliary device was applied.

Conclusions

According to the FEA results, the new spinal protection device can effectively prevent and treat osteoporotic vertebral compression fractures (OVCFs), and can alter the stress distribution in the spine and reduce the stress in the anterior column of the vertebral body, especially in vertebral compression fractures.

Assessment of Osteoporosis in Lumbar Spine: In Vivo Quantitative MR Imaging of Collagen Bound Water in Trabecular Bone

AIM

Bone collagen matrix makes a crucial contribution to the mechanical properties of bone by imparting tensile strength and elasticity. The collagen content of bone is accessible via quantification of collagen bound water (CBW) indirectly. We prospectively study the performance of the CBW proton density (CBWPD) measured by a 3D short repetition time adiabatic inversion recovery prepared ultrashort echo time (STAIR-UTE) magnetic resonance imaging (MRI) sequence in the diagnosis of osteoporosis in human lumbar spine.

METHODS

A total of 189 participants with a mean age of 56 (ranged from 50 to 86) years old were underwent MRI, quantitative computed tomography (QCT), and dual-energy X-ray absorptiometry (DXA) in lumbar spine. Major fracture risk was also evaluated for all participants using Fracture Risk Assessment Tool (FRAX). Lumbar CBWPD, bone marrow fat fraction (BMFF), bone mineral density (BMD) and T score values were calculated in three vertebrae (L2-L4) for each subject. Both the CBWPD and BMFF were correlated with BMD, T score, and FRAX score for comparison. The abilities of the CBWPD and BMFF to discriminate between three different cohorts, which included normal subjects, patients with osteopenia, and patients with osteoporosis, were also evaluated and compared using receiver operator characteristic (ROC) analysis.

RESULTS

The CBWPD showed strong correlation with standard BMD (R² = 0.75, P < 0.001) and T score (R² = 0.59, P < 0.001), as well as a moderate correlation with FRAX score (R² = 0.48, P < 0.001). High area under the curve (AUC) values (≥ 0.84 using QCT as reference; ≥ 0.76 using DXA as reference) obtained from ROC analysis demonstrated that the CBWPD was capable of well differentiating between the three different subject cohorts. Moreover, the CBWPD had better correlations with BMD, T score, and FRAX score than BMFF, and also performed better in cohort discrimination.

CONCLUSION

The STAIR-UTE-measured CBWPD is a promising biomarker in the assessment of bone quality and fracture risk.

Deep learning approach for automatic segmentation of ulna and radius in dual-energy X-ray imaging

BACKGROUND

Segmentation of the ulna and radius is a crucial step for the measurement of bone mineral density (BMD) in dual-energy X-ray imaging in patients suspected of having osteoporosis.

PURPOSE

This work aimed to propose a deep learning approach for the accurate automatic segmentation of the ulna and radius in dual-energy X-ray imaging.

METHODS AND MATERIALS

We developed a deep learning model with residual block (Resblock) for the segmentation of the ulna and radius. Three hundred and sixty subjects were included in the study, and five-fold cross-validation was used to evaluate the performance of the proposed network. The Dice coefficient and Jaccard index were calculated to evaluate the results of segmentation in this study.

RESULTS

The proposed network model had a better segmentation performance than the previous deep learning-based methods with respect to the automatic segmentation of the ulna and radius. The evaluation results suggested that the average Dice coefficients of the ulna and radius were 0.9835 and 0.9874, with average Jaccard indexes of 0.9680 and 0.9751, respectively.

CONCLUSION

The deep learning-based method developed in this study improved the segmentation performance of the ulna and radius in dual-energy X-ray imaging.

Fully automated opportunistic screening of vertebral fractures and osteoporosis on more than 150,000 routine computed tomography scans

OBJECTIVE

Osteoporosis is underdiagnosed and undertreated, although severe complications of osteoporotic fractures, including vertebral fractures, are well known. This study sought to assess the feasibility and results of an opportunistic screening of vertebral fractures and osteoporosis in a large database of lumbar or abdominal CT scans.

MATERIAL AND METHODS

Data were analyzed from CT scans obtained in 35 hospitals from patients aged 60 years and more and stored in a Picture Archiving and Communication System in Assistance-Publique-Hôpitaux de Paris, from 2007 to 2013. Dedicated software analyzed the presence of at least 1 vertebral fracture (VF), and measured Hounsfield Units (HU) in lumbar vertebrae. A simulated T-score was calculated.

RESULTS

Data were analyzed from 152 268 patients (73.2 ± 9.07 years). Success rates for VF assessment and HU measurements were 82 and 87% respectively. Prevalence of VF was 24.5% and increased with age. Areas under the receiver operating characteristic curves for the detection of VF were 0.61 and 0.62 for mean HU of lumbar vertebrae and L1 HU, respectively. In patients without VF, HU decreased with age, similarly in males and females. The prevalence of osteoporosis (sT-score ≤ - 2.5) was 23.8% and 36.5% in patients without and with VFs respectively.

CONCLUSION

Opportunistic screening in patients 60 years and older having lumbar or abdominal CT scans is feasible at large scale to screen vertebral fractures and osteoporosis.

The Indian Society for Bone and Mineral Research (ISBMR) position statement for the diagnosis and treatment of osteoporosis in adults

The Indian Society for Bone and Mineral Research (ISBMR) has herein drafted clinical practice guidelines for the diagnosis and management of osteoporosis for the people of India. Implementation of the position statement in clinical practice is expected to improve the overall care of patients with osteoporosis in India.

PURPOSE

In India, osteoporosis is a major public health problem. However, in the absence of any robust regional guidelines, the screening, treatment, and follow-up of patients with osteoporosis are lagging behind in the country.

METHODS

The Indian Society for Bone and Mineral Research (ISBMR), which is a multidisciplinary group of physicians, researchers, dietitians, and epidemiologists and who study bone and related tissues, in their annual meeting, drafted the guidelines for the diagnosis and management of osteoporosis that would be appropriate in a resource constraint setting like India.

RESULTS

Diagnosis of osteoporosis can be made in a patient with minimal trauma fracture without the aid of any other diagnostic tools. In others, bone mineral density measured by dual-energy X-ray absorptiometry remains the modality of choice. Data indicates that osteoporotic fractures occur at an earlier age in Indians than in the West; hence, screening for osteoporosis should begin at an earlier age. FRAX can be used for fracture risk estimation; however, it may underestimate the risk of future fractures in our population and still needs validation. Maintaining optimum serum 25-hydroxyvitamin D levels is essential, which, in most cases, would require regular vitamin D supplementation. Pharmacotherapy should be guided by the presence/absence of vertebral/hip fractures or the severity of risk based on clinical factors, although bisphosphonates remain the first choice in most cases. Regular follow-up is essential to ensure adherence and response to therapy.

CONCLUSIONS

Implementation of the position statement in clinical practice is expected to improve the overall care of patients with osteoporosis in India.

Developing a model Fracture Liaison Service consultation with patients, carers and clinicians: a Delphi survey to inform content of the iFraP complex consultation intervention

Fracture Liaison Services are recommended to deliver best practice in secondary fracture prevention. This modified Delphi survey, as part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) study, provides consensus regarding tasks for clinicians in a model Fracture Liaison Service consultation.

PURPOSE

The clinical consultation is of pivotal importance in addressing barriers to treatment adherence. The aim of this study was to agree to the content of the 'model Fracture Liaison Service (FLS) consultation' within the iFraP (Improving uptake of Fracture Prevention drug Treatments) study.

METHODS

A Delphi survey was co-designed with patients and clinical stakeholders using an evidence synthesis of current guidelines and content from frameworks and theories of shared decision-making, communication and medicine adherence. Patients with osteoporosis and/or fragility fractures, their carers, FLS clinicians and osteoporosis specialists were sent three rounds of the Delphi survey. Participants were presented with potential consultation content and asked to rate their perception of the importance of each statement on a 5-point Likert scale and to suggest new statements (Round 1). Lowest rated statements were removed or amended after Rounds 1 and 2. In Round 3, participants were asked whether each statement was 'essential' and percentage agreement calculated; the study team subsequently determined the threshold for essential content.

RESULTS

Seventy-two, 49 and 52 patients, carers and clinicians responded to Rounds 1, 2 and 3 respectively. One hundred twenty-two statements were considered. By Round 3, consensus was reached, with 81 statements deemed essential within FLS consultations, relating to greeting/introductions; gathering information; considering therapeutic options; eliciting patient perceptions; establishing shared decision-making preferences; sharing information about osteoporosis and treatments; checking understanding/summarising; and signposting next steps.

CONCLUSIONS

This Delphi consensus exercise has summarised for the first time patient/carer and clinician consensus regarding clearly defined tasks for clinicians in a model FLS consultation.

Fragility fracture identifies patients at imminent risk for subsequent fracture: real-world retrospective database study in Ontario, Canada

BACKGROUND

The secondary fracture prevention gap in the osteoporosis field has been previously described as a 'crisis'. Closing this gap is increasingly important in the context of accumulating evidence showing that an incident fragility fracture is associated with an increased risk of subsequent fracture within 1-2 years, known as imminent fracture risk. The objective of this study was to use health services data to characterize the time between index fragility fractures occurring at different osteoporotic sites and subsequent fractures.

METHODS

This retrospective observational study used de-identified health services data from the publicly funded healthcare system in Ontario, the largest province of Canada. Patients aged > 65 with an index fragility fracture occurring between 2011 and 2015 were identified from the ICES Data Repository using International Classification of Diseases (ICD)-10 codes. We examined median time to subsequent fragility fractures for osteoporotic fracture sites until the end of follow-up (2017). BMD assessment and use of osteoporosis therapies following index fracture were also characterized.

RESULTS

Among 115,776 patients with an index fragility fracture, 17.8% incurred a second fragility fracture. Median time between index and second fracture occurring at any site was 555 days (interquartile range: 236-955). For each index fracture site examined, median time from index to second fracture was < 2 years. The proportion of patients with BMD assessment was 10.3% ≤1 year prior to and 16.4% ≤1 year post index fracture. The proportion of patients receiving osteoporosis therapy was 29.8% ≤1 year prior, 34.6% ≤1 year post, and 25.9% > 3 years post index fracture.

CONCLUSIONS

This cohort of Canadian patients aged > 65 years who experienced a fragility fracture at any site are at imminent risk of experiencing subsequent fracture within the next 2 years and should be proactively assessed and treated.

Genomic Medicine: Lessons Learned From Monogenic and Complex Bone Disorders

Current genetic studies of monogenic and complex bone diseases have broadened our understanding of disease pathophysiology, highlighting the need for medical interventions and treatments tailored to the characteristics of patients. As genomic research progresses, novel insights into the molecular mechanisms are starting to provide support to clinical decision-making; now offering ample opportunities for disease screening, diagnosis, prognosis and treatment. Drug targets holding mechanisms with genetic support are more likely to be successful. Therefore, implementing genetic information to the drug development process and a molecular redefinition of skeletal disease can help overcoming current shortcomings in pharmaceutical research, including failed attempts and appalling costs. This review summarizes the achievements of genetic studies in the bone field and their application to clinical care, illustrating the imminent advent of the genomic medicine era.

Automated Abdominal CT Imaging Biomarkers for Opportunistic Prediction of Future Major Osteoporotic Fractures in Asymptomatic Adults

Background Body composition data from abdominal CT scans have the potential to opportunistically identify those at risk for future fracture. Purpose To apply automated bone, muscle, and fat tools to noncontrast CT to assess performance for predicting major osteoporotic fractures and to compare with the Fracture Risk Assessment Tool (FRAX) reference standard. Materials and Methods Fully automated bone attenuation (L1-level attenuation), muscle attenuation (L3-level attenuation), and fat (L1-level visceral-to-subcutaneous [V/S] ratio) measures were derived from noncontrast low-dose abdominal CT scans in a generally healthy asymptomatic adult outpatient cohort from 2004 to 2016. The FRAX score was calculated from data derived from an algorithmic electronic health record search. The cohort was assessed for subsequent future fragility fractures. Subset analysis was performed for patients evaluated with dual x-ray absorptiometry (n = 2106). Hazard ratios (HRs) and receiver operating characteristic curve analyses were performed. Results A total of 9223 adults were evaluated (mean age, 57 years ± 8 [standard deviation]; 5152 women) at CT and were followed over a median time of 8.8 years (interquartile range, 5.1-11.6 years), with documented subsequent major osteoporotic fractures in 7.4% (n = 686), including hip fractures in 2.4% (n = 219). Comparing the highest-risk quartile with the other three quartiles, HRs for bone attenuation, muscle attenuation, V/S fat ratio, and FRAX were 2.1, 1.9, 0.98, and 2.5 for any fragility fracture and 2.0, 2.5, 1.1, and 2.5 for femoral fractures, respectively (P < .001 for all except V/S ratio, which was P ≥ .51). Area under the receiver operating characteristic curve (AUC) values for fragility fracture were 0.71, 0.65, 0.51, and 0.72 at 2 years and 0.63, 0.62, 0.52, and 0.65 at 10 years, respectively. For hip fractures, 2-year AUC for muscle attenuation alone was 0.75 compared with 0.73 for FRAX (P = .43). Multivariable 2-year AUC combining bone and muscle attenuation was 0.73 for any fragility fracture and 0.76 for hip fractures, respectively (P ≥ .73 compared with FRAX). For the subset with dual x-ray absorptiometry T-scores, 2-year AUC was 0.74 for bone attenuation and 0.65 for FRAX (P = .11). Conclusion Automated bone and muscle imaging biomarkers derived from CT scans provided comparable performance to Fracture Risk Assessment Tool score for presymptomatic prediction of future osteoporotic fractures. Muscle attenuation alone provided effective hip fracture prediction. © RSNA, 2020 See also the editorial by Smith in this issue.

Undertreatment of osteoporosis following hip fracture: a retrospective, observational study in Singapore

Undertreatment of osteoporosis after hip fracture increases the risk of death, disability, recurrent osteoporotic fractures, and financial burden. Only half were compliant with osteoporosis medications. Elderly patients were less persistent and compliant to treatment. Denosumab was associated with a higher proportion of days covered by osteoporosis medications than oral bisphosphonates.

PURPOSE

The aim of this study was to identify factors that contributed to the initiation of osteoporosis medications following hip fracture as well as the compliance and persistence to osteoporosis medications.

METHODS

Clinical data of 532 patients older than 50 years old admitted for surgical fixation of hip fractures were reviewed. Three hundred forty-seven had sufficient data for analysis after excluding patients with non-fragility fractures. Prescription for any osteoporosis medication in the year following hip fracture as well as compliance to treatment was evaluated.

RESULTS

Only 40.3% of patients were prescribed with osteoporosis medication within 1 year post-hip fracture. Females (p = 0.020) performing dual-energy x-ray absorptiometry scan (p < 0.001) and 25 hydroxyvitamin D levels testing post-hip fracture (p < 0.027) were independent determinants of increased likelihood of being prescribed with osteoporosis medication. Patients with proportion of days covered (PDC) ≥ 0.8 (or 80% of days covered in a year) were defined as compliant. Overall, only 49.7% of the patients were compliant with osteoporosis medications. Elderly patients aged 70-79 years (p = 0.002) and males (p = 0.017) were less persistent with osteoporosis treatment when compared with patients aged < 69 years and females. The compliance was poorer in patients aged 70-79 years (p = 0.026) as compared with those under 69 years of age. Statistically significant difference (p = 0.032) was observed between mean PDC of oral bisphosphonates (0.66) and denosumab (0.83). Only 39.3% of patients were persistent with treatment at 1 year.

CONCLUSION

Our findings demonstrate the urgent need to increase awareness through a structured protocol of osteoporosis treatment. A multi-disciplinary Fracture Liaison Service should be set up to ensure compliance to osteoporosis medication post-hip fracture.