The influence of family history of hip fracture on the risk of vertebral deformity in men and women: the European Vertebral Osteoporosis Study

Predictors of fragility fracture and low bone mineral density in patients with a history of parental fracture

Objectives

Bone mineral density (BMD) and fragility fracture (FF) have high heritability, but few data exist on impact of other factors on families with fracture history. We aimed to evaluate predictors of FF and low BMD, in patients with family history of FF.

Methods

This was a retrospective study on patients undergoing dual energy X-ray absorptiometry at a district general hospital (DGH), 2004–2016. Parameters recorded (in addition to standard dual energy X-ray absorptiometry parameters): age, smoking, alcohol, corticosteroids, aromatase inhibitors, Depo-Provera, hormone replacement therapy, rheumatoid arthritis, polymyalgia rheumatica, breast or prostate cancer, coeliac disease, and fracture site. Logistic regression was used to model fracture risk and site, and linear regression for impact of factors on L1–4 and femoral BMD. Factor analyses with polychoric correlation matrices and calculation of Eigenvalues were applied to determine association between fracture sites and associated risk factors.

Results

A total of 6053 patients were included, 91.1% female. 2094 had sustained at least one FF. Smoking, alcoholism, increased age, height, and fat mass increased FF risk. Sites analysed: femur, tibia/fibula, humerus, forearm, ribs, and vertebrae. Alcoholism, and increasing tissue thickness and fat mass significantly increased FF risk. Decreased right femoral and vertebral BMD increased overall FF risk.

Conclusions

Our study confirms the effect of certain factors on vertebral BMD, but suggests a differential effect on the upper and lower spine, as well as in the dominant and nondominant hip. Different sites of fracture are associated with different risk factors, the most common sites of fracture being the peripheral long bones and vertebrae.

Objectively Verified Parental Hip Fracture Is an Independent Risk Factor for Fracture: a Linkage Analysis of 478,792 Parents and 261,705 Offspring

Parental hip fracture (HF) is considered a major risk factor for offspring major osteoporotic fracture (MOF), but all studies to date have relied on self-reported information of uncertain accuracy. We tested the association of objectively verified parental HF with offspring MOF and HF. We used a population-based historical cohort study of 261,705 offspring (age ≥40 years) with at least one linked parent (total 478,792 parents) for the province of Manitoba, Canada. Cox proportional hazards models were developed to test hazard ratio (HR) for offspring MOF and HF for 1997 to 2014 according to prior parental HF dating back to 1970. The median age of offspring at study entry was 40 years (range, 40 to 50 years), and 48.3% were women. During 2.9 million person-years of offspring follow-up (median per offspring, 12 years), we identified 7323 incident MOF (4.4% versus 2.7% for those with and without a parental HF, p < 0.001), including 331 HF (0.3% versus 0.1%, p < 0.001). Parental HF was independently associated with increased risk of offspring MOF (HR, 1.30; 95% confidence interval [CI], 1.20 to 1.41). The strength of the association decreased with older parental age at HF (ptrend  < 0.001), and was no longer significant if parental HF occurred after age 80 years (adjusted HR, 1.07; 95% CI, 0.96 to 1.19). The relationship between parental HF and offspring HF was even stronger than for MOF (adjusted HR, 1.64; 95% CI, 1.21 to 2.23). Associations with MOF or HF were not affected by either the gender of the parent with HF or the gender of the offspring. Parental HF increased the risk for offspring MOF and HF but not when parental HF occurred after age 80 years. This suggests a more nuanced approach for clinicians trying to stratify fracture risk, and illustrates the enormous potential of parent-offspring record linkage for other familial disorders. © 2016 American Society for Bone and Mineral Research.

The influence of osteoporosis in trauma

Osteoporosis is a descriptive term for a loss of bone mass and structure which predisposes to fracture in response to minimal trauma. These fractures cause pain, disability and significant mortality, with enormous resource costs to health and other services. Proximal femoral (hip) fractures account for most of the mortality and cost, and an estimated six million osteoporosis-related hip fractures occur world-wide each year, a number likely to increase dramatically due to changes in population demographics. The diagnosis of osteoporosis should be considered in all patients over the age of 50 years who sustain a fracture, unless there is obvious major trauma. Not only will this inform immediate management but it also allows measures aimed at prevention of further fractures to be implemented. Early surgery is often effective in limiting morbidity from osteoporotic fractures and in older people is best planned in collaboration with other health care professionals.

Association between the ACE gene I/D polymorphism and osteoporosis in a Turkish population

PURPOSE

The purpose of this study was to assess the relationship between osteoporosis and the angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism in a Turkish population.

METHODS

The study group consisted of 238 unrelated women with osteoporosis and 124 unrelated healthy female controls. All participants, patients and healthy controls, were of Turkish origin from the central region of Turkey. Genomic DNA was isolated from whole venous blood samples using a commercial DNA isolation kit. The ACE gene I/D polymorphism was analysed by polymerase chain reaction and gel electrophoresis.

RESULTS

Frequencies of the DD, ID and II genotypes in the patients were 44.5, 41.2 and 14.3 %, and in the controls they were 25.0, 51.6 and 23.4 %, respectively. A significant difference was observed between patients and controls according to genotype frequency (p=0.001). D and I allele frequencies of the I/D polymorphism were 65.1 and 34.9 % in the patient group and 50.8 and 49.2 % in the control group, respectively (p<0.001).

CONCLUSION

The ACE gene I/D polymorphism could be a genetic factor associated with osteoporosis.

Clinical review. Risk factors for low bone mass-related fractures in men: a systematic review and meta-analysis

CONTEXT

Testing men at increased risk for osteoporotic fractures has been recommended.

OBJECTIVE

The aim of this study was to estimate the magnitude of association and quality of supporting evidence linking multiple risk factors with low bone mass-related fractures in men.

DATA SOURCES

We searched MEDLINE, EMBASE, Web of Science, SCOPUS and Cochrane CENTRAL through February 2010. We identified further studies by reviewing reference lists from selected studies and reviews.

STUDY SELECTION

Eligible studies had to enroll men and quantitatively evaluate the association of risk factors with low bone density-related fractures.

DATA EXTRACTION

Reviewers working independently and in duplicate determined study eligibility and extracted study description, quality, and outcome data.

DATA SYNTHESIS

Fifty-five studies provided data sufficient for meta-analysis. The quality of these observational studies was moderate with fair levels of multivariable adjustment and adequate exposure and outcome ascertainment. Statistically significant associations were established for age, low body mass index, current smoking, excessive alcohol use, chronic corticosteroid use, history of prior fractures, history of falls, history of hypogonadism, history of stroke, and history of diabetes. Statistical heterogeneity of the meta-analytic estimates of all associations was significant except for chronic corticosteroid use. None of these associations were of large magnitude (i.e. adjusted odds ratios were generally <2). No evidence supporting a particular effective testing or screening strategy was identified.

CONCLUSIONS

Multiple risk factors for fractures in men were identified, but their usefulness for stratifying and selecting men for bone density testing remains uncertain.

Multifactorial analysis of risk factors for reduced bone mineral density among postmenopausal women

INTRODUCTION

The study aimed to determine the risk factors for reduced bone mineral density (BMD) among postmenopausal women.

MATERIAL AND METHODS

Two hundred and fifty-three postmenopausal women were included to the study. The study group consisted of 85 women with osteoporosis (mean age: 59.9 years) and 168 with osteopenia (mean age: 57.8 years). Patients were assigned to groups according to their BMD measured in the lumbar spine, hip and femoral neck by dual X-ray absorptiometry. Bone formation was assessed by measuring serum osteocalcin and bone resorption by measuring serum C-terminal type I α-collagen chain telopeptide.

RESULTS

Multiple regression analysis for lumbar spine showed association of age (p = 0.001), parental history of fracture (p = 0.05), use of hormone replacement therapy (p = 0.034), bisphosphonates therapy (p < 0.001), calcium and vitamin D supplements therapy (p = 0.001), oestradiol level (p = 0.007) and body mass index (p < 0.001). Multiple regression analysis for femoral neck and hip total showed association of age (p = 0.001), parental history of fracture (p = 0.049), use of bisphosphonates (p < 0.03)) use of calcium and vitamin D supplements (p = 0.039), oestradiol level (p = 0.047). All the variables together explain 40.4% of variance in BMD for the lumbar spine and 25.6% of variance in BMD for femoral neck and hip total.

CONCLUSIONS

The present study demonstrated correlations between the variables and BMD, which are known and widely described in the literature. Osteoporosis and osteopenia in Polish subjects appear to be associated with several known risk factors that are well described in the literature.

Official Positions for FRAX® clinical regarding prior fractures from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®

The 2010 Position Development Conference addressed four questions related to the impact of previous fractures on 10-year fracture risk as calculated by FRAX(®). To address these questions, PubMed was searched on the keywords "fracture, epidemiology, osteoporosis." Titles of retrieved articles were reviewed for an indication that risk for future fracture was discussed. Abstracts of these articles were reviewed for an indication that one or more of the questions listed above was discussed. For those that did, the articles were reviewed in greater detail to extract the findings and to find additional past work and citing works that also bore on the questions. The official positions and the supporting literature review are presented here. FRAX(®) underestimates fracture probability in persons with a history of multiple fractures (good, A, W). FRAX(®) may underestimate fracture probability in individuals with prevalent severe vertebral fractures (good, A, W). While there is evidence that hip, vertebral, and humeral fractures appear to confer greater risk of subsequent fracture than fractures at other sites, quantification of this incremental risk in FRAX(®) is not possible (fair, B, W). FRAX(®) may underestimate fracture probability in individuals with a parental history of non-hip fragility fracture (fair, B, W). Limitations of the methodology include performance by a single reviewer, preliminary review of the literature being confined to titles, and secondary review being limited to abstracts. Limitations of the evidence base include publication bias, overrepresentation of persons of European descent in the published studies, and technical differences in the methods used to identify prevalent and incident fractures. Emerging topics for future research include fracture epidemiology in non-European populations and men, the impact of fractures in family members other than parents, and the genetic contribution to fracture risk.

Predicting risk of osteoporotic fracture in men and women in England and Wales: prospective derivation and validation of QFractureScores

OBJECTIVE

To develop and validate two new fracture risk algorithms (QFractureScores) for estimating the individual risk of osteoporotic fracture or hip fracture over 10 years.

DESIGN

Prospective open cohort study with routinely collected data from 357 general practices to develop the scores and from 178 practices to validate the scores.

SETTING

General practices in England and Wales.

PARTICIPANTS

1 183 663 women and 1 174 232 men aged 30-85 in the derivation cohort, who contributed 7 898 208 and 8 049 306 person years of observation, respectively. There were 24 350 incident diagnoses of osteoporotic fracture in women and 7934 in men, and 9302 incident diagnoses of hip fracture in women and 5424 in men.

MAIN OUTCOME MEASURES

First (incident) diagnosis of osteoporotic fracture (vertebral, distal radius, or hip) and incident hip fracture recorded in general practice records.

RESULTS

Use of hormone replacement therapy (HRT), age, body mass index (BMI), smoking status, recorded alcohol use, parental history of osteoporosis, rheumatoid arthritis, cardiovascular disease, type 2 diabetes, asthma, tricyclic antidepressants, corticosteroids, history of falls, menopausal symptoms, chronic liver disease, gastrointestinal malabsorption, and other endocrine disorders were significantly and independently associated with risk of osteoporotic fracture in women. Some variables were significantly associated with risk of osteoporotic fracture but not with risk of hip fracture. The predictors for men for osteoporotic and hip fracture were age, BMI, smoking status, recorded alcohol use, rheumatoid arthritis, cardiovascular disease, type 2 diabetes, asthma, tricyclic antidepressants, corticosteroids, history of falls, and liver disease. The hip fracture algorithm had the best performance among men and women. It explained 63.94% of the variation in women and 63.19% of the variation in men. The D statistic values for discrimination were highest for hip fracture in women (2.73) and men (2.68) and were over twice the magnitude of the corresponding values for osteoporotic fracture. The ROC statistics for hip fracture were also high: 0.89 in women and 0.86 for men versus 0.79 and 0.69, respectively, for the osteoporotic fracture outcome. The algorithms were well calibrated with predicted risks closely matching observed risks. The QFractureScore for hip fracture also had good performance for discrimination and calibration compared with the FRAX (fracture risk assessment) algorithm.

CONCLUSIONS

These new algorithms can predict risk of fracture in primary care populations in the UK without laboratory measurements and are therefore suitable for use in both clinical settings and for self assessment (www.qfracture.org). QFractureScores could be used to identify patients at high risk of fracture who might benefit from interventions to reduce their risk.

Association analysis of WNT10B with bone mass and structure among individuals of African ancestry

Wnts comprise a family of secreted growth factors that regulate the development and maintenance of many organs. Recently, Wnt10b was shown to stimulate osteoblastogenesis and bone formation in mice. To evaluate further the role of Wnt10b in bone health in humans, we performed bidirectional sequencing of approximately 8 kb of the WNT10B gene region in 192 individuals (96 African, 96 white) to identify single nucleotide polymorphisms (SNPs). We identified 19 SNPs with minor allele frequency (MAF) > or =0.01. Ten of these SNPs were not present in the NCBI dbSNP database (build 127), whereas 10 of the 20 SNPs (50%) reported in dbSNP were not verified. We initially genotyped seven tagging SNPs that captured common (MAF > or = 0.05) variation in the region with r (2) > 0.80 and a potentially functional SNP in exon 5 in 1035 Afro-Caribbean men > or =40 yr of age. Association analysis showed three SNPs in a 3' region of linkage disequilibrium that were associated with DXA measures of hip BMD. Associations between two of these three SNPs (rs1051886, rs3741627) with hip BMD were replicated in an additional 980 Afro-Caribbean men (p < 0.05), in the combined sample of 2015 men (p < or = 0.006), and in 416 individuals > or =18 yr of age (mean, 44 yr) belonging to eight extended, multigenerational Afro-Caribbean families with mean family size >50 (3535 relative pairs; p < 0.05). Further analysis showed that rs1051886 and rs3741627 were associated with cortical cross-sectional area, periosteal circumference, and BMC in the radius, such that individuals with the minor alleles had lower biomechanical indices of long-bone bending strength. This analysis implicates the WNT10B locus as a genetic element in the regulation of bone mass and structural geometry.

Osteoporosis in men

Osteoporosis has long been considered to be a disease of the aging female skeleton. As awareness of the pervasiveness of this disorder increases, it is clear that men are also at risk for this disorder. Recent epidemiological studies have confirmed that osteoporosis in men is an increasing health problem. This development not only has its roots in increased longevity but also in increased awareness of this problem in men. The purpose of this article is to review what is known about the factors in men that lead to acquisition, maintenance, and loss of bone, as well as new insights about the causes, pathogenesis, and treatment of osteoporosis in men.

Relationship between risk factors and QUS in a European Population: The OPUS study

There are many risk factors associated with low bone mineral density. Quantitative ultrasound (QUS) is a generally accepted method for measurement of bone and has been shown to be strongly associated with future fracture risk. The Osteoporosis and Ultrasound Study (OPUS) is a multi-centre European wide study examining 5 different QUS scanners (4 calcaneal, 1 finger device). The aim of this paper was to examine the relationship between risk factors (as assessed by questionnaire) and QUS measurements. 449 younger women (aged 20 to 39 years) and 2283 older women (aged 55 to 79 years) were included in this analysis. As expected, those with a self-reported previous fracture had lower QUS measurements than those without (P < 0.001). However, no significant difference was seen between those reporting a maternal hip fracture and those who did not report such an event. Differences were found for smokers vs. non-smokers for SOS but not for BUA measurements. Weight was positively correlated with all BUA variables but only with some SOS variables. We determined which risk factors were most strongly associated with QUS measurements by using step-wise multiple regression. Models for each QUS measurement were calculated, and the R2 values ranged from 0.18 to 0.28 for SOS, 0.27 to 0.32 for BUA and 0.31 to 0.42 for the finger QUS device. The most common risk factors across all models were age, use of hormone replacement therapy, self-reported previous fracture, self-reported diagnosis of osteoporosis, current weight, pulse rate and self-reported estimated height at age 20 years. We analysed relationships across the 5 centres and detected some geographical differences in the prevalence of the risk factors. In conclusion, similar relationships are seen with QUS measurements as are found for bone mineral density. However, the strength of the association is dependent on the type of QUS device and variable measured.

Assessment of fracture risk: Who should be treated for osteoporosis?

The clinical significance of osteoporosis arises from the fractures that occur. Of these, the hip fracture in particular is associated with high morbidity, mortality and socio-economic costs. The primary goal of osteoporosis treatment is fracture prevention. In this chapter we try to answer the question of how to assess fracture risk and how to identify those above a given risk threshold so that treatment can be given to those in whom fractures can be prevented (cost-) effectively. At first, the two main strategies for fracture prevention--population screening and case finding--are discussed. Then a fracture risk assessment score, based on easily identifiable clinical risk factors, is proposed. This clinical risk factor analysis can guide the decisions whether additional bone assessment is relevant and whether treatment should be started. Finally, we advocate that absolute fracture risk is important for communication with the patient about the decision whether or not to initiate treatment.

Bone mineral density, body height, and vitamin D receptor gene polymorphism in middle-aged men

BACKGROUND

Polymorphisms of the vitamin D receptor (VDR) gene have been suggested to account for some of the genetic variation in bone mass. However, the relationship has been controversial. It has been suggested that environmental factors such as physical activity may be one of the many reasons for this controversy.AIM. We investigated the possible interactions of VDR gene polymorphisms and low to moderate intensity exercise on bone mineral density (BMD) in a four-year controlled, randomized intervention trial in 140 middle-aged Finnish men.

METHOD

The TaqI, FokI, and ApaI restriction fragment length polymorphism (RFLP)-markers of the VDR gene were evaluated. BMDs of the lumbar spine (L2-L4), femoral neck, and total proximal femur were measured with dual-energy X-ray absorptiometry (DXA). In addition, the relations of the VDR gene polymorphism with bone turnover markers (serum tartrate-resistant acid phosphatase (TRAP) 5b activity and serum osteocalcin concentration) were evaluated.

RESULTS

At the randomization, the subjects with the VDR TaqI Tt or tt genotype had a greater body height than the subjects with TT genotype (P=0.001). In addition, the association of VDR TaqI polymorphism with femoral BMD was found. The Tt or tt genotype associated with higher femoral neck values than the TT genotype (P=0.003) at randomization. After adjusting the femoral neck for body height, the association remained (P=0.021). We did not find any association between VDR gene polymorphism and bone turnover markers or any interactions of VDR gene polymorphisms and exercise on BMD.

CONCLUSIONS

The TaqI polymorphism may be associated with body height and femoral neck BMD values. The present findings also suggest that the VDR polymorphisms do not modify the effect of regular aerobic exercise on BMD. However, more randomized controlled exercise trials are needed to investigate the role of exercise intensity on VDR gene polymorphisms, and the role of VDR gene polymorphisms on BMD.

Maternal history of osteoporosis and femur geometry

Most studies that have examined the role of skeletal factors in the relationship between an individual's family history of fracture or osteoporosis and their fracture risk have focused on bone density. In this study, we expanded the scope of skeletal factors to include geometric properties (subperiosteal width, section modulus, cortical thickness, and buckling ratio) in addition to areal bone mineral density (BMD). We compared these skeletal factors at the femur neck and shaft by self-reported maternal history of osteoporosis (OP HX) from 5334 non-Hispanic whites, ages > or =20 years in the Third National Health and Nutrition Examination Survey (NHANES III, 1988-94). A total of 213 men and 315 women reported a positive OP HX (e.g., their biological mother had sustained a hip fracture after age 50 years or had a physician's diagnosis of osteoporosis). Differences in bone density and geometry by OP HX were examined after adjusting for potential confounding variables. Several bone parameters differed significantly by OP HX in both sexes at the femur neck, but none differed at the femur shaft. At the neck, those with a positive OP HX had values that differed by approximately 3% to 4% (lower for BMD, bone mineral content (BMC), cross-sectional area, and cortical thickness; higher for buckling ratios) from those with a negative OP HX (P < 0.05). The magnitude of these relationships was similar in both sexes, but differences were greater in younger versus older adults. In conclusion, both men and women with a positive maternal history of osteoporosis may be at greater risk of femur neck fracture owing to thinner cortices and lower BMC, which in turn results in potentially greater cortical instability (buckling ratio) at this skeletal site.

Risk factors for incident vertebral fractures in men and women: the Rotterdam Study

Low BMD and prevalent vertebral fractures are known risk factors for incident vertebral fractures. In 3001 men and women from the Rotterdam Study, prevalent nonvertebral fractures, early menopause, current smoking, and walking aid use were also strong risk factors for incident vertebral fractures.

INTRODUCTION

Thus far, age, low BMD, and prevalent vertebral fractures are the only well-known risk factors for incident vertebral fractures. Therefore, our aim was to investigate other potential risk factors for incident vertebral fractures in the elderly.

MATERIALS AND METHODS

This study was based on the Rotterdam Study, a large prospective population-based cohort study among men and women > or =55 years of age. For 3001 subjects, spinal radiographs were obtained at baseline and again approximately 6.3 years later. These follow-up radiographs were scored for vertebral fractures using the McCloskey-Kanis method. Whenever a vertebral fracture was detected, the radiograph was compared with the baseline radiograph. If this fracture was not already present at baseline, it was considered incident. At baseline, information on potential risk factors was obtained.

RESULTS

Low BMD and prevalent vertebral fractures were strong risk factors for incident vertebral fractures in both men and women (RR 2.3 [1.6-3.3] and 2.2 [0.9-5.0] for men and RR 2.1 [1.6-2.6] and 4.1 [2.5-6.7] for women, respectively). For women, age, early menopause (< or =45 years of age; RR 1.0 [1.1-3.5]), current smoking (2.1 [1.2-3.5]), and walking aid use (2.5 [1.1-5.5]) were additional independent risk factors. For men, only a history of nonvertebral fractures was a significant independent risk factor (OR 2.4 [1.2-4.8]).

CONCLUSION

Apart from low BMD and prevalent vertebral fractures, prevalent nonvertebral fractures are associated with an increased incident vertebral fracture risk in men. In women, early menopause, current smoking, and walking aid use are additional independent risk factors for incident vertebral fractures.

Osteoporosis in men: epidemiology, diagnosis, prevention, and treatment

BACKGROUND

Osteoporosis and fragility fractures in men account for substantial health care expenditures and decreased quality of life.

OBJECTIVE

This article reviews the most current information about the epidemiology, diagnosis, prevention, and treatment of osteoporosis in men.

METHODS

Relevant literature was identified through a search of MEDLINE (1966-June 2003) limited to English-language studies in men. The search terms included fractures, bone density, or osteoporosis plus either epidemiology, diagnosis, prevention, control, or therapy. Additional search terms included specific subtopics (eg, bisphosphonates, calcium, exercise, parathyroid hormone). The authors contributed additional relevant publications.

RESULTS

Morbidity after fragility fracture is at least as high in men as in women, and the rate of fracture-related mortality 1 year hip fracture is approximately double in men compared with women. The bioavailable fraction of testosterone slowly declines into the ninth decade in men. There is evidence that the effect of estrogen on bone is greater than that of testosterone in men. Diagnosing osteoporosis in men is complicated by a lack of consensus on how it should be defined. Significant risk factors for osteoporosis or fracture include low bone mineral density, previous fragility fracture, maternal history of fracture, marked hypogonadism, smoking, heavy alcohol intake or alcoholism, low calcium intake, low body mass or body mass index, low physical activity, use of bone-resorbing medication such as glucocorticoids, and the presence of such conditions as hyperthyroidism, hyperparathyroidism, and hypercalciuria. Prevention is paramount and should begin in childhood. During adulthood, calcium (1000-1500 mg/d), vitamin D (400-800 IU/d), and adequate physical activity play crucial preventive roles. When treatment is indicated, the bisphosphonates are the first choice, whereas there is less support for the use of calcitonin or androgen therapy. Parathyroid hormone (1-34) is a promising anabolic therapy. There is also strong evidence for the use of bisphosphonates for the treatment of glucocorticoid-induced osteoporosis.

Single nucleotide polymorphisms in the human gene for osteoprotegerin are not related to bone mineral density or fracture in elderly women

Osteoprotegerin (OPG), a secreted member of the tumor necrosis factor receptor family, is a potent inhibitor of osteoclast activation and differentiation. In animal models OPG prevents bone loss, and in humans bone resorption can be reduced by injections of OPG. OPG may also play a role in cardiovascular disease since mice lacking the OPG gene display arterial calcification. In a screening effort of the OPG gene, we recently discovered a single nucleotide polymorphism in the promoter region of OPG (T950C), and reported an association with vascular morphology and function in 59 healthy individuals. Due to the pronounced effect of OPG on bone turnover, the present study was conducted to investigate whether OPG polymorphisms are also associated with bone mineral density or with fracture. The relationship between single nucleotide polymorphisms in the promoter region of OPG (T950C) and the first intron (C1217T), and bone mineral density, measured by DXA in the hip or spine or ultrasound of the heel, was investigated in the Malmö OPRA-study of 1044 women, all 75 years old. The possible relation to fracture incidence was also analyzed. Among the 858 and 864 individuals respectively, genotyped, no significant associations between the investigated single nucleotide polymorphisms and bone mineral density measurements (T950C P = 0.50-0.64, C1217T P = 0.51-1.00), quantitative ultrasound measurements of the calcaneus, or fractures (T950C P = 0.61-0.66, C1217T P = 0.14-0.33) were found. Thus, our results show that polymorphisms in the OPG gene, one of which has previously been found to be associated with cardiovascular morphology and function, are not associated with bone mineral density in elderly Swedish women.

Performance of quantitative ultrasound in the discrimination of prevalent osteoporotic fractures in a bone metabolic unit

There is a growing interest in ultrasound evaluation of bone status as an alternative to the measurement with dual X-ray absorptiometry (DXA), due to its low cost, portability, and nonionizing radiation. The aim of our study was to investigate the relation among DXA, QUS, clinical, anthropometric, and lifestyle factors, and to determine QUS cutoff values in order to discriminate fractures in patients referred to the Bone Metabolic Unit at an Endocrinology Service. We studied 300 patients (281 females and 19 males; age 58 +/- 11 years) referred for evaluation of osteoporosis. In all cases we determined basic anthropometric parameters, a clinical history including previous osteoporotic fractures and risk factors for osteoporosis, and QUS parameters in calcaneus (Hologic Sahara), and BMD in lumbar spine (LS) and femoral neck (FN), by DXA (Hologic QDR 1000). Using the WHO densitometric criteria, 37, 46.7, and 16.3% of our population were osteoporotic, osteopenic, and normal, respectively. A QUI T-score </=-1.5 SD provided a sensitivity of 68.9% and a specificity of 64.7% for osteoporotic fracture discrimination and a sensitivity of 64.9% and a specificity of 74.1% for osteoporosis defined by WHO criteria using DXA. In the logistic regression, the presence of family history of fragility fractures (OR: 3.03; CI 95%: 1.3-7.03), a DXA T-score </=-2.5 (OR: 3.58; CI 95%: 1.66-7.73), and a QUI T-score </=-1.5 (OR: 2.56; CI 95%: 1.15-5.69) were independently associated with prevalent osteoporotic fractures. In conclusion, calcaneus ultrasound appears as a useful technique for the routine clinical practice, as its performance is similar to DXA for the discrimination of subjects with osteoporotic fracture.

Risk factors for Colles' fracture in men and women: results from the European Prospective Osteoporosis Study

The aim of this study was to determine the contribution of constitutional and lifestyle variables on the subsequent risk of distal forearm (Colles') fracture in a multinational, multicenter, population-prospective study. A total of 15,745 subjects from the European Vertebral Osteoporosis Study, who had completed a baseline questionnaire on lifestyle and constitutional factors, were followed up annually using a validated questionnaire to ascertain the occurrence of new fractures. Risks are expressed as hazard ratios (with 95% confidence intervals) derived from a Cox proportional hazards regression model. The incidence of Colles' fracture was 1.7 and 7.3 per 1000 person years in men and women, respectively. In women delayed menarche, over the age of 15 years, was associated with a modest increased risk [HR 1.5 (range 1.1-2.0)]. Regular walking in that group also increased the risk [HR 1.6 (1.2-2.2)] perhaps reflecting the increased exposure to risk of falling. None of the other factors examined revealed any important influences. The results are broadly in line with the few other published prospective studies suggesting only a modest role for these factors in influencing susceptibility to fracture.

Osteoporosis in men: pathophysiology, evaluation, and therapy

Osteoporosis is a serious health problem for men. An advance in our understanding of the pathophysiology and treatment of this disorder has resulted in the possibility of a gender-specific approach to screening, diagnosis, and treatment. Here we review the data on osteoporosis in men, discuss controversies regarding whom to screen, whom to treat, and how to treat. Recent treatment data as they relate to men are reviewed, and a clinical treatment algorithm is presented.

Genetics of osteoporosis: role of steroid hormone receptor gene polymorphisms

Osteoporosis is a common skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture. In the past years, twin and family study have shown that this disease recognizes a strong genetic component and that genetic factors play an important role in regulating bone mineral density (BMD). While in few isolate conditions osteoporosis can be inherited in a simple Mendelian pattern, due to single gene mutations, in the majority of cases has to be considered a multifactorial polygenic disease in which genetic determinants are modulated by hormonal, environmental and nutritional factors. Given the important role that steroid hormones play in bone cell development and in the maintenance of normal bone architecture, polymorphisms at receptor of the steroid/thyroid hormone receptor superfamily, such as estrogen receptor alpha (ERalpha) and Vitamin D receptor (VDR) have been thoroughly investigated in the last years and appeared to represent important candidate genes. The individual contribution of these genetic polymorphisms to the pathogenesis of osteoporosis remains to be universally confirmed and an important aim in future work will be to define their functional molecular consequences and how these polymorphisms interact with each other and with the environment to cause the osteoporotic phenotype. A further promising application of genetic studies in osteoporosis comes from their pharmacogenomic implications, with the possibility to give a better guidance for therapeutic agents commonly used to treat this invalidating disorder or to identify target molecules for new therapeutic agents.

A common promotor variant in the cytochrome P450c17alpha (CYP17) gene is associated with bioavailability testosterone levels and bone size in men

Cytochrome P450c17alpha (CYP17) encodes an enzyme with 17a-hydroxylase and 17,20-lyase activities, which is essential for the normal production of adrenal and gonadal androgens. Because androgens have powerful effects on bone growth and metabolism, we determined whether a single base pair (bp) substitution (T-->C) in the promoter region (-34 bp) of CYP17 is associated with sex hormone levels, stature, and femoral mass and size in 333 white men aged 51-84 years (mean +/- SD; 66+/-7 years). Femoral neck bone mineral content (BMC), cross-sectional area (CSA), and bone mineral density (BMD) were measured using dual-energy X-ray absorptiometry (DXA). Genotype frequencies did not deviate from Hardy-Weinberg expectations. Serum bioavailable testosterone levels were 20% or 0.5 SDs higher in men with the C/C compared with the T/T genotype, whereas heterozygous men had intermediate hormone levels (p = 0.019). Men with the C/C genotype also were nearly 3 cm taller and had 0.6 SD greater femoral neck CSA than men with the T/T genotype (p < or = 0.01 for both). The association with CSA persisted after adjusting for age, height, and body weight. In contrast, CYP17 genotype was not associated with femoral neck BMC, areal BMD (g/cm2), or estimated volumetric BMD (g/cm3). These results suggest that allelic variation at the CYP17 locus may contribute to the genetic influence on stature and femoral size in men.

The role of bone turnover markers and risk factors in the assessment of osteoporosis and fracture risk

The clinical evaluation of osteoporosis in individual patients involves confirmation of the diagnosis, the investigation of secondary causes of osteoporosis and the evaluation of subsequent fracture risk. Optimum clinical assessment involves bone mineral densitometry with the treatment thresholds modified by clinical risk factors for individual patients. Bone turnover markers and clinical risk factors can be used to identify patients at risk of osteoporotic fracture and those who have secondary osteoporosis. Risk assessment should involve the evaluation of absolute rather than relative risk. Further work is required to improve the integration of clinical risk factors, bone turnover markers and bone densitometry into appropriate models to enable the assessment of the absolute risk of fracture for individual patients.

Risk factors for vertebral deformities in men: relationship to number of vertebral deformities. European Vertebral Osteoporosis Study Group

Recent epidemiological studies suggest a similar overall prevalence of vertebral deformity in men to that in women, though the influence of increasing age on the prevalence of vertebral deformity is less marked in men. However, most affected men have only a single or two vertebral deformities, which may be unrelated to osteoporosis. The aim of this study was to examine the role of risk factors, previously demonstrated to be associated with vertebral osteoporosis in females, in men with single/dual deformities compared to those with multiple deformities. Age stratified random samples of men aged 50 years and over were recruited from population registers in 30 European centers as part of the European Vertebral Osteoporosis Study (EVOS). Subjects had a lateral spinal radiograph and the presence of vertebral deformity was determined using the McCloskey algorithm. Lifestyle and other risk factor data were obtained from an interviewer-administered questionnaire. In all 6937 men with a mean age of 64.4 (SD = 8.5) years were studied of whom 738 (10.6%) subjects had one or two deformities, and 109 (1.6%) subjects had three or more deformities. There was a marked increase in the prevalence of multiple vertebral deformities with increasing age, but only a modest effect of age on the prevalence of single deformities. Associations between various risk factors for osteoporosis and vertebral deformity were analyzed separately in men with single/dual vertebral deformity from those with three or more deformities using logistic regression. After adjustment for age, there were statistically significant associations between the following risk factors and multiple deformities: previous hip fracture (odds ratio [OR] 10.5), lack of regular physical activity (OR 2.9), low body mass (OR 2.5), and previous steroid use (OR 2.3). By contrast, there were only weak associations with these same variables in males with single/dual deformities and, apart from poor self-reported general health, all of the 95% confidence intervals spanned unity. There was no difference in the reporting of very heavy levels of physical activity under the age of 50 years between men with single/dual deformities and those with multiple deformities. In conclusion, men with multiple deformities showed a similar pattern of risk factor association to those seen in women with vertebral deformity, in contrast to men with single/dual deformities.

Familial resemblance of bone mineral density (BMD) and calcaneal ultrasound attenuation: the BMD in mothers and daughters study

The familial resemblance in bone mineral density (BMD) and calcaneal broadband ultrasound attenuation (BUA) was examined in 207 mother-daughter pairs. Mothers were participants in the Study of Osteoporotic Fractures. Three groups of daughters were recruited based on their maternal history of "fracture," "low BMD" without fracture (< 0.58 g/cm2, t-score < -2.5), and "normal BMD" without fracture (> 0.67 g/cm2, t-score > -1.6). Data on other potentially heritable factors known to influence BMD and BUA were also collected. BMD was measured at the hip, spine, whole body, and calcaneus. Calcaneal BUA was assessed using the Walker-Sonix UBA 575. Total hip and femoral neck BMD were significantly lower (5.0-8.0%, p < 0.017) among daughters, in particular premenopausal daughters, of mothers with established osteoporosis ("fracture" or "low BMD") compared with daughters of mothers at lower risk of osteoporosis ("normal BMD"). BUA did not differ across daughter groups. Lifestyle characteristics (dietary calcium, smoking, physical activity) were not highly correlated in mothers and daughters. Height, weight, and body composition were significantly correlated within mother-daughter pairs and could be a potential mechanism by which BMD is inherited. Among pre- and postmenopausal daughters, heritability estimates ranged from 50-63% and 34-48%, respectively. Heritability for calcaneal BUA (53%) was evident among postmenopausal daughters only. In conclusion, familial association in BMD was strongest among premenopausal daughters. Estimates of heritability suggest that maternal BMD and BUA are important independent predictors of BMD and BUA among daughters, reinforcing the importance of prevention and early intervention among women with a positive family history of osteoporosis.

The genetics of osteoporosis: vitamin D receptor polymorphisms

Osteoporosis is a metabolic bone disease characterized by low bone mass and deterioration of bone tissue that leads to bone fragility and an increase in fracture risk. It is a disease with a complex etiology that includes genetic and environmental contributors. Environmental factors that influence bone density include dietary factors-such as intakes of calcium, alcohol, and caffeine-and lifestyle factors-such as exercise and smoking. Ethnic differences in the propensity to nontraumatic bone fracture suggest that genetic factors are important. Recently, common allelic variations in he vitamin D receptor gene have been found to be associated with bone mineral density in racially diverse population groups, as well as in prepubertal girls, young adult and postmenopausal women, and men. However, many studies have not been able to find this association. Additional approaches, such as sib-pair analysis, will probably be necessary in the future to identify the important determinants of osteoporosis.

Osteoporosis in men

Osteoporosis in men has become better recognized as an important health problem, particularly in the aged. Nevertheless, the knowledge available remains limited and fragmentary. Many clinical decisions must be based on extrapolations from the more complete understanding of osteoporosis in women. Gender differences in the causation and manifestation of the disease are probable, and the following issues clearly require better definition: Pathomechanisms. What are the determinants of age-related bone loss and fractures? What is the nature of idiopathic osteoporosis? How do other medical conditions result in osteoporosis? Cost-effective strategies for disease detection. Strategies for the prevention and treatment of bone loss and for the prevention of fractures.

[Localization and extent of tissue damage caused by extracorporeal lithotripsy (ESWL)]

Extracorporeal shock wave lithotripsy (ESWL) causes proteinuria. In our study we investigated the protein fractions and the electrolyte composition of the urine in patients who had been treated with ESWL. The aim was to obtain information on the degree and the localisation of the glomerular, tubular or vascular destruction caused by ESWL in humans. A total of 34 patients with stones had been treated with ESWL. As parameters we used: urine output, creatinine clearance, total protein, albumin, immunoglobulin G, N-acetyl-beta-D-glucosaminidase (beta-NAG), alpha-1-microglobulin, the fractional excretion of Na+ and apolipoprotein-A-1. After ESWL treatment proteinuria and albuminuria are found. Our parameters show no deterioration of the glomerula or the tubulus. The increase in apolipoprotein-A-1, a postglomerular parameter, however, is interpreted as a manifestation of vascular destruction after ESWL; this is normally temporary, leaving no permanent damage.