Treatment of postmenopausal osteoporosis

Insights into pelvic insufficiency fracture following pelvic radiotherapy for cervical cancer: a comparative review

BACKGROUND

Radiotherapy (RT)-induced pelvic insufficiency fractures (PIF) are prevalent in patients with cervical cancer. Inconclusive studies on PIF after cervical irradiation create uncertainty. This review examined PIF after RT in cervical patients, including its pathobiology, likely locations of fractures, incidence, clinical symptoms, and predisposing factors. We further discussed study limitations and therapeutic possibilities of PIF.

METHODS

The following online resources were searched for relevant articles: Google Scholar and PubMed. The keywords 'pelvic insufficiency fractures', 'cervical carcinoma' and 'cervical cancer', as well as 'chemoradiotherapy', 'chemoradiation', and 'radiotherapy', were some of the terms that were used during the search.

RESULTS

Patients with PIF report pelvic pain after radiation treatment for cervical cancer; the incidence of PIF ranges from 1.7 to 45.2%. Evidence also supports that among all patients treated with pelvic radiation, those who experienced pelvic insufficiency fractures invariably had at least one sacral fracture, making it the most frequently fractured bone in the body. Menopausal status, weight, BMI, age, and treatments and diagnosis modalities can influence PIF during radiotherapy.

CONCLUSIONS

In conclusion, our comparative review of the literature highlights significant heterogeneity in various aspects of PIF following radiation for patients with cervical cancer. This diversity encompasses prevalence rates, associated risk factors, symptoms, severity, diagnosis methods, preventive interventions, and follow-up periods. Such diversity underscores the complexity of PIF in this population and emphasizes the critical need for further research to elucidate optimal management strategies and improve patient outcomes.

Comparative Clinical Effects and Risk Factors Associated With Vitamin D in Foot and Ankle Fracture and Arthrodesis Healing

Vitamin D deficiency in relation to bone metabolism and healing has been controversial and not well studied. However, hypovitaminosis has been widely identified within the orthopedic patient population. The current best evidence suggests a lack of data on this important topic. The ability to assess patients for optimum bone healing and metabolism is still in question due to lack of a suitable reliable biomarker and multiple other unknown variables affecting bone metabolism. To compound this effect, popular dermatological precautions in the last 20 to 30 years of avoiding sunlight also have the effect of further reducing serum vitamin D production in the skin. As a proof of concept, we performed a preliminary comparative observational retrospective review of orthopedic patients undergoing fracture and arthrodesis osseous healing to determine how serum vitamin D levels are associated with bone healing along with their confounding comorbidities. Based on our review, the current accepted vitamin D levels (≥20 ng/mL) are low and insufficient for fractures and for arthrodesis osseous healing due to observed high rates (>35%) of delayed unions, and an increased (>90%) in the number of multiple confounding comorbidities affecting bone healing process that are often not mentioned or captured in this type of study in previous literature. Obesity and diabetes are significant contributory risks factors, and the preliminary findings suggest that the current accepted adequate levels may not be enough for osseous healing. These low vitamin D levels appear to affect bone healing and prolong treatment, with worsening trends with diabetes and obesity comorbidities.

Safety and efficacy of sequential treatments for postmenopausal osteoporosis: a network meta-analysis of randomised controlled trials

Background

The sequential anti-osteoporotic treatment for women with postmenopausal osteoporosis (PMO) is important, but the order in which different types of drugs are used is confusing and controversial. Therefore, we performed a network meta-analysis to compare the efficacy and safety of available sequential treatments to explore the most efficacious strategy for long-term management of osteoporosis.

Methods

In this network meta-analysis, we searched the PubMed, EMBASE, Web of Science, the Cochrane Library, and ClinicalTrials.gov from inception to September 19, 2023 to identify randomised controlled trials comparing sequential treatments for women with PMO. The identified trials were screened by reading the title and abstract, and only randomised clinical trials involving sequential anti-osteoporotic treatments and reported relevant outcomes for PMO were included. The main outcomes included vertebral fracture risk, the percentage change in bone mineral density (BMD) in different body parts, and all safety indicators in the stage after switching treatment. A frequentist network meta-analysis was performed using the multivariate random effects method and evaluated using the surface under the cumulative ranking curve (SUCRA). Certainty of evidence was assessed using the Confidence in the Network Meta-Analysis (CINeMA) framework. This study is registered with PROSPERO: CRD42022360236.

Findings

A total of 19 trials comprising 18,416 participants were included in the study. Five different sequential treatments were investigated as the main interventions and compared to the corresponding control groups. The intervention groups in this study comprised the following treatment switch protocols: switching from an anabolic agent (AB) to an anti-resorptive agent (AR) (ABtAR), transitioning from one AR to another AR (ARtAAR), shifting from an AR to an AB (ARtAB), switching from an AB to a combined treatment of AB and AR (ABtC), and transitioning from an AR to a combined treatment (ARtC). A significant reduction in the incidence of vertebral fractures was observed in ARtC, ABtAR and ARtAB in the second stage, and ARtC had the lowest incidence with 81.5% SUCRA. ARtAAR and ABtAR were two effective strategies for preventing fractures and improving BMD in other body parts. Especially, ARtAAR could improve total hip BMD with the highest 96.1% SUCRA, and ABtAR could decrease the risk of total fractures with the highest 94.3% SUCRA. Almost no difference was observed in safety outcomes in other comparisons.

Interpretation

Our findings suggested that the ARtAAR and ABtAR strategy are the effective and safe sequential treatment for preventing fracture and improving BMD for PMO. ARtC is more effective in preventing vertebral fractures.

Funding

The National Natural Science Foundation of China (82170900, 81970762), the Hunan Administration of Traditional Chinese Medicine, and the Hunan Province High-level Health Talents "225" Project.

Anti-Müllerian Hormone promotes human osteoblast differentiation and calcification by modulating osteogenic gene expression

OBJECTIVE

To investigate whether the Anti-Müllerian Hormone (AMH), an ovarian hormone belonging to the Transforming Growth Factor β superfamily, may represent a possible candidate for use as a bone anabolic factor.

METHODS

We performed in vitro studies on Human Osteoblasts (HOb) to evaluate the expression and the functionality of AMHRII, the AMH receptor type-2, and investigate the effects of exogenous AMH exposure on osteogenic gene expression and osteoblast functions.

RESULTS

We reported the first evidence for the expression and functionality of AMHRII in HOb cells, thus suggesting that osteoblasts may represent a specific target for exogenous AMH treatment. Furthermore, the exposure to AMH exerted a stimulatory effect on HOb cells leading to the activation of osteogenic genes, including the upregulation of osteoblastic transcription factors such as RUNX and OSX, along with increased deposition of mineralized nodules.

CONCLUSION

Our findings proved interesting clues on the stimulatory effects of AMH on mature osteoblasts expressing its specific receptor, AMHRII. This study may therefore have translation value in opening the perspective that AMH may be an effective candidate to counteract the bone loss in osteoporotic patients by selectively targeting osteoblast with minimal off-target effect.

A Brief Review of Bone Cell Function and Importance

This review focuses on understanding the macroscopic and microscopic characteristics of bone tissue and reviews current knowledge of its physiology. It explores how these features intricately collaborate to maintain the balance between osteoblast-mediated bone formation and osteoclast-mediated bone resorption, which plays a pivotal role in shaping not only our physical framework but also overall health. In this work, a comprehensive exploration of microscopic and macroscopic features of bone tissue is presented.

Total body bone mineral density and various spinal disorders: a Mendelian randomization study

Introduction

Observational studies have yielded inconsistent findings regarding the correlation between bone mineral density (BMD) and various spinal disorders. To explore the relationship between total-body BMD and various spinal disorders further, we conducted a Mendelian randomization analysis to assess this association.

Methods

Two-sample bidirectional Mendelian randomization (MR) analysis was employed to investigate the association between total-body BMD and various spinal disorders. The inverse-variance weighted (IVW) method was used as the primary effect estimate, and additional methods, including weighted median, MR-Egger, simple mode, and weighted mode, were used to assess the reliability of the results. To examine the robustness of the data further, we conducted a sensitivity analysis using alternative bone-density databases, validating the outcome data.

Results

MR revealed a significant positive association between total-body BMD and the prevalence of spondylosis and spinal stenosis. When total-body BMD was considered as the exposure factor, the analysis demonstrated an increased risk of spinal stenosis (IVW odds ratio [OR] 1.23; 95% confidence interval [CI], 1.14-1.32; P < 0.001) and spondylosis (IVW: OR 1.24; 95%CI, 1.16-1.33; P < 0.001). Similarly, when focusing solely on heel BMD as the exposure factor, we found a positive correlation with the development of both spinal stenosis (IVW OR 1.13, 95%CI, 1.05-1.21; P < 0.001) and spondylosis (IVW OR 1.10, 95%CI, 1.03-1.18; P = 0.0048). However, no significant associations were found between total-body BMD and other spinal disorders, including spinal instability, spondylolisthesis/spondylolysis, and scoliosis (P > 0.05).

Conclusion

This study verified an association of total-body BMD with spinal stenosis and with spondylosis. Our results imply that when an increasing trend in BMD is detected during patient examinations and if the patient complains of numbness and pain, the potential occurrence of conditions such as spondylosis or spinal stenosis should be investigated and treated appropriately.

The Relationship between Bone Mineral Densitometry and Visceral Adiposity Index in Postmenopausal Women

OBJECTIVE

 It was aimed to compare visceral adiposity index (VAI) levels in patients with normal bone mineral density (BMD), osteopenia, and osteoporosis.

METHODS

 One hundred twenty postmenopausal women (40 with normal BMD, 40 with osteopenia, and 40 with osteoporosis) between the ages of 50 to 70 years were included in the study. For females, the VAI was calculated using the formula (waist circumference [WC]/[36.58 + (1.89 x body mass index (BMI))]) x (1.52/High-density lipoprotein [HDL]-cholesterol [mmol/L]) x (triglyceride [TG]/0.81 [mmol/L]).

RESULTS

 The time of menopause from the beginning was similar in all groups. Waist circumference was found to be higher in those with normal BMD than in the osteopenic and osteoporotic groups (p = 0.018 and p < 0.001, respectively), and it was also higher in the osteopenic group than in the osteoporotic group (p = 0.003). Height and body weight, BMI, blood pressure, insulin, glucose, HDL-cholesterol, and homeostasis model assessment-insulin resistance (HOMA-IR) levels were similar in all groups. Triglyceride levels were found to be higher in the normal BMD group, compared with the osteoporotic group (p = 0.005). The level of VAI was detected as higher in those with normal BMD, compared with the women with osteoporosis (p = 0.002). Additionally, the correlation analysis showed a positive correlation between dual-energy X-ray absorptiometry (DXA) spine T-scores, WC, VAI, and a negative correlation between DXA spine T-scores and age.

CONCLUSION

 In our study, we found higher VAI levels in those with normal BMD, compared with women with osteoporosis. We consider that further studies with a larger sample size will be beneficial in elucidating the entity.

Exercise for osteoporosis: A literature review of pathology and mechanism

Osteoporosis (OP) is a disease that weakens bones and has a high morbidity rate worldwide, which is prevalent among the elderly, particularly, women of postmenopausal age. The dynamic balance between bone formation and resorption is necessary for normal bone metabolism. Many factors, including aging, estrogen deficiency, and prolonged immobilization, disrupt normal apoptosis, autophagy, and inflammation, leading to abnormal activation of osteoclasts, which gradually overwhelm bone formation by bone resorption. Moderate exercise as an effective non-drug treatment helps increase bone formation and helps relieve OP. The possible mechanisms are that exercise affects apoptosis and autophagy through the release of exercise-stimulated myohormone and the secretion of anti-inflammatory cytokines via mechanical force. In addition, exercise may also have an impact on the epigenetic processes involved in bone metabolism. Mechanical stimulation promotes bone marrow mesenchymal stem cells (BMSCs) to osteogenic differentiation by altering the expression of non-coding RNAs. Besides, by reducing DNA methylation, the mechanical stimulus can also alter the epigenetic status of osteogenic genes and show associated increased expression. In this review, we reviewed the possible pathological mechanisms of OP and summarized the effects of exercise on bone metabolism, and the mechanisms by which exercise alleviates the progression of OP, to provide a reference for the prevention and treatment of OP.

A Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Study of Jianyao Migu Granules in the Treatment of Osteopenic Low Back Pain

Purpose

This randomized controlled trial aimed to evaluate the clinical efficacy of Jianyao Migu granules (JYMGG) in the treatment of primary osteopenic low back pain (LBP).

Patients and Methods

A total of 108 patients with primary osteopenic LBP were randomly divided into the JYMGG group and placebo group. Both groups took 600 mg of oral Caltrate D daily; in addition, the JYMGG group was given oral JYMGG, while the placebo group was given placebo granules. The treatment period was 6 months for both groups. The pre- to post-treatment changes in the bone mineral density (BMD), visual analogue scale (VAS) score, Oswestry disability index (ODI), and bone turnover markers were compared between the two groups.

Results

The post-treatment VAS score and ODI were significantly lower than baseline in both groups (P<0.05). In the JYMGG group, the lumbar BMD increased from 0.88±0.07 g/cm2 to 0.90±0.13 g/cm2 and the hip BMD increased from 0.77±0.08 g/cm2 to 0.78±0.10 g/cm2, giving increases of 2.70% and 1.96% respectively, but the differences were not statistically significant. The post-treatment levels of ALP, osteocalcin, P1NP, and β-CTX were increased compared with baseline in both groups, but the differences were not statistically significant. The thyrotropin level was significantly increased after treatment in the placebo group (P<0.05). There were no abnormalities detected in routine blood and kidney function tests performed during the observation period. Some patients showed elevated liver enzymes and gastrointestinal reactions.

Conclusion

JYMGG effectively relieved the bone pain, and improved the quality of life of patients with primary osteopenic LBP.

Prescreening for osteoporosis with forearm bone densitometry in health examination population

BACKGROUND

Early detection and timely prophylaxis can retard the progression of osteoporosis. The purpose of this study was to determine the validity of peripheral Dual Energy X-ray Absorptiometry (DXA) test for osteoporosis screening. We examined peripheral bone mineral density (BMD) using AKDX-09 W-I DXA densitometer. Firstly, we acquired BMD data from manufacturer-supplied density-gradient phantoms and 30 volunteers to investigate its accuracy and precision, then we measured BMD for 150 volunteers using both AKDX (left forearm) and Hologic Discovery Wi (left forearm, left hip and L1 - L4 vertebrae) simultaneously. Correlation relationship of BMD results acquired from two instruments was assessed by simple linear regression analysis, the Receiver Operating Characteristic (ROC) curves and Areas Under the Curves (AUCs) were evaluated for the diagnostic value of left forearm BMD measured by AKDX in detecting osteoporosis.

RESULTS

In vitro precision errors of AKDX BMD were 0.40, 0.20, 0.19%, respectively, on low-, medium-, and high-density phantom; in vivo precision was 1.65%. Positive correlation was observed between BMD measured by AKDX and Hologic at the forearm (r = 0.670), L1-L4 (r = 0.430, femoral neck (r = 0.449), and total hip (r = 0.559). With Hologic measured T-score as the gold standard, the sensitivity of AKDX T-score < - 1 for identifying suboptimal bone health was 63.0 and 76.1%, respectively, at the distal one-third radius and at any site, and the specificity was 73.9 and 90.0%, respectively; the AUCs were 0.708 and 0.879. The sensitivity of AKDX T-score ≤ - 2.5 for identifying osteoporosis at the distal one-third radius and at any site was 76.9 and70.4%, respectively, and the specificity was 80.4 and 78.0%, respectively; the AUCs were 0.823 and 0.778.

CONCLUSIONS

Peripheral DXA appears to be a reliable tool for prescreening for osteoporosis.

Ferroptosis: A New Regulatory Mechanism in Osteoporosis

Osteoporosis can be caused by a multitude of factors and is defined by a decrease in bone density and mass caused by the destruction of bone microstructure, resulting in increased bone brittleness. Thus, it is a systemic bone disease in which patients are prone to fracture. The role of ferroptosis in the pathogenesis of osteoporosis has become a topic of growing interest. In this review, we discuss the cell morphology, basic mechanisms of ferroptosis, the relationship between ferroptosis and osteoclasts and osteoblasts, as well as the relationship between ferroptosis and diabetic osteoporosis, steroid-induced osteoporosis, and postmenopausal osteoporosis. Emerging biomedical research has provided new insights into the roles of ferroptosis and osteoporosis, such as in cellular function, signaling pathways, drug inhibition, and gene silencing. The pathophysiology and mechanism of ferroptosis and osteoporosis need to be further studied and elucidated to broaden our understanding of iron metabolism and immune regulation. Studies using animal models of osteoporosis in vivo and cell models in vitro will help clarify the relationship between ferroptosis and osteoporosis and provide research ideas for the elucidation of new mechanisms and development of new technologies and new drugs for the treatment of osteoporosis in the future.

In vitro and in silico anti-osteoporosis activities and underlying mechanisms of a fructan, ABW90-1, from Achyranthes bidentate

Achyranthes bidentata is a traditional Chinese medicine used to treat osteoporosis. AB90, a crude saccharide from A. bidentata, showed excellent osteoprotective effects in ovariectomized rats, and ABW90-1, an oligosaccharide purified from AB90, stimulated significant differentiation of osteoblasts. However, the osteogenic effects and underlying mechanisms of ABW90-1 have remained unknown. In the present study, we found that ABW90-1 significantly promoted ALP activity, mineralization, and the expression of osteogenic markers in MC3T3-E1 cells. ABW90-1 showed strong binding with the WNT signaling complex and BMP2 based on number of interactions, hydrogen bond length, and binding energy in silico. ABW90-1 significantly increased the expression of active-β-catenin, p-GSK-3β, LEF-1, BMP2, and p-SMAD1. Importantly, the osteogenic effects of ABW90-1 were partially suppressed by DKK-1 and Noggin, which are specific inhibitors of the WNT and BMP signaling pathways, respectively. Collectively, these findings suggest that ABW90-1 has osteogenic effects through crosstalk between WNT/β-catenin and BMP2/SMAD1 signaling pathways.

Comparative Analysis of T-score Discordance between a Registry-Based Korean Population and Atypical Femoral Fracture Patients of a Single Institution

Background

The purpose of this study was to analyze the epidemiology of T-score discordance between the spine and femur in the South Korean population and compare the prevalence of T-score discordance between the Korean osteoporosis population and atypical femoral fracture (AFF) patients.

Methods

A total of 12,422 subjects from the Korea National Health and Nutrition Examination Survey were reviewed retrospectively. T-score discordance was defined as a difference of ≥ 1 standard deviation between the lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD). The prevalence of T-score discordance (low LS [LS BMD < FN BMD], low FN [LS BMD > FN BMD], and total [low LS + low FN]) was investigated in the osteoporosis and non-osteoporosis groups and stratified by sex and age. T-score discordance of 63 patients with AFFs diagnosed at a single institution was compared with that of the Korean osteoporosis population using propensity score matching.

Results

T-score discordance was prevalent in the Korean osteoporosis population (44.8%), and low LS discordance (37.5%) was more frequently seen than low FN discordance (7.2%) (p < 0.001). The prevalence of total and low LS discordance was significantly higher in AFF patients than in the Korean osteoporosis population (total discordance: 69.8% and 42.5%, respectively; low LS discordance: 63.5% and 31.7%, respectively; p < 0.001).

Conclusions

T-score discordance was highly prevalent in the Korean osteoporosis population, and low LS discordance was more common than low FN discordance. Nevertheless, the prevalence of low LS discordance was significantly higher in AFF patients than in the Korean osteoporosis population.

Necroptosis: A new target for prevention of osteoporosis

Multiple causes may contribute to osteoporosis, characterized by a loss in bone mass and density as a consequence of the degradation of bone microstructure and a resultant rise in bone fragility. Recently, increasing attention has been paid to the role of necroptosis in the development of osteoporosis. Necroptosis is orchestrated by a set of proteins known as receptor-interacting protein kinase (RIPK)1, RIPK3, and mixed lineage kinase domain-like protein (MLKL). A necrosome is formed by MLKL, RIPK1, RIPK3, and RIPK3-RIPK3. A dissociated MLKL forms pores in the plasma membrane and eventually leads to necroptosis after translocating from the necrosome. In this review, we discuss a detailed understanding of necroptosis and its associated processes, a better understanding of its interactions with osteoclasts, osteoblasts, and osteocytes, and the associations between necroptosis and diabetic osteoporosis, steroid-induced osteoporosis, and postmenopausal osteoporosis. In addition, a variety of experimental medicines capable of modulating crucial necroptosis processes are highlighted. It's important to note that this is the first review paper to consolidate current data on the role of necroptosis in osteoporosis, and it offers fresh hope for the future treatment of this disease.

The Effects of Osteoporotic and Non-osteoporotic Medications on Fracture Risk and Bone Mineral Density

Osteoporosis is a highly prevalent bone disease affecting more than 37.5 million individuals in the European Union (EU) and the  United States of America (USA). It is characterized by low bone mineral density (BMD), impaired bone quality, and loss of structural and biomechanical properties, resulting in reduced bone strength. An increase in morbidity and mortality is seen in patients with osteoporosis, caused by the approximately 3.5 million new osteoporotic fractures occurring every year in the EU. Currently, different medications are available for the treatment of osteoporosis, including anti-resorptive and osteoanabolic medications. Bisphosphonates, which belong to the anti-resorptive medications, are the standard treatment for osteoporosis based on their positive effects on bone, long-term experience, and low costs. However, not only medications used for the treatment of osteoporosis can affect bone: several other medications are suggested to have an effect on bone as well, especially on fracture risk and BMD. Knowledge about the positive and negative effects of different medications on both fracture risk and BMD is important, as it can contribute to an improvement in osteoporosis prevention and treatment in general, and, even more importantly, to the individual's health. In this review, we therefore discuss the effects of both osteoporotic and non-osteoporotic medications on fracture risk and BMD. In addition, we discuss the underlying mechanisms of action.

Vitamin D status in Armenian women: a stratified cross-sectional cluster analysis

Background

Vitamin D plays a critical role in skeletal development and maintenance, thus sufficiency is an important goal for public health programs. Given the absence of foods fortified in vitamin D in Armenia, we hypothesized that vitamin D insufficiency would be widespread.

Methods

We conducted a random modified cluster model survey of vitamin D status of women in the country. We measured 25-hydroxyvitamin D [25(OH)D] by liquid chromatography mass spectrometry in dried blood spot samples and utilized a questionnaire to assess lifestyle factors.

Results

In summer, we sampled 1206 participants from 40 communities in Armenia. Mean 25-OH D level among women aged 18–24 was 20 ± 8 ng/mL; aged 25–64 was 21 ± 7 ng/mL; and >65 was 18 ± 8 ng/mL. The country-wide mean of the entire female population was 20 ± 8 ng/mL. A majority (>54%) had 25-OH D levels <20 ng/mL with nearly 13% having 25-OH D levels <12 ng/mL. Participants who reported calcium, vitamin D, or multivitamin supplementation had higher levels of 25-OH D (p values 0.004, 0.0002, and 0.03 respectively) as did pre- vs. postmenopausal women (p = 0.01), pregnant vs. nonpregnant women (p = <0.0001), and women who had experienced a sunburn in the past year (p = 0.004).

Conclusion

In Armenia, there is a high prevalence of vitamin D insufficiency. This information provides data that can be used to inform public health directives to address this pervasive threat to optimal health.

Effects of Drynaria Total Flavonoid on the Microstructure of the Mandible in Ovariectomized Rats

Background

The aim of this study is to investigate the effects of Drynaria total flavonoids (DTF) on mandible microarchitecture, serum estrogen (E2), osteoprotegerin (OPG), and receptor activator of nuclear factor kappa-B ligand (RANKL) levels in an ovariectomy-induced osteoporosis rat model.

Material/Methods

Thirty female Sprague-Dawley rats were divided into 5 groups (n=6 per group): sham surgery, ovariectomy (OVX), and low-dose, middle-dose, and high-dose DTF. Mandibular osteoporosis was induced by ovariectomy; an equal amount of ovary-sized fat tissue was removed from the sham group. The DTF-treated groups were given DTF gavage at different doses for 12 weeks; the sham and OVX groups were given saline. After the treatment phase, the effects of DTF on the microarchitecture of the mandible were evaluated by measuring bone density, maximum load, morphometric parameters, and histopathological alterations. Serum E2, OPG, and RANKL levels were measured.

Results

The OVX group showed obvious osteoporosis in the mandible and decreased serum E2 levels and OPG/RANKL ratio. The low-dose group did not show significant improvement in mandibular microstructure. The middle-dose group showed significantly ameliorated osteoporosis. The high-dose group had further improvement in bone microstructures and increase of OPG/RANKL over the middle-dose group. Furthermore, ovariectomy significantly decreased serum E2, but DTF treatment failed to restore serum E2 levels.

Conclusions

Ovariectomy can cause significant bone loss in the rat mandible and a decrease in serum E2 and OPG/RANKL. DTF significantly improved the mandibular microstructure and restored OPG/RANKL balance, but it did not restore the decreased serum E2 concentration following ovariectomy.

Unveiling the Pharmacological Mechanisms of Eleutheroside E Against Postmenopausal Osteoporosis Through UPLC-Q/TOF-MS-Based Metabolomics

Postmenopausal osteoporosis (PMOP) is a common metabolic bone disease in postmenopausal women in the Worldwide, and seriously affects the quality of life of middle-aged and elderly women. Therefore, there is an urgent need to discover a highly effective drug for PMOP treatment. In this study, ultra-high performance liquid tandem quadrupole time-of-flight mass spectrometry (UPLC-Q/TOF-MS) was used to analyze the urine metabolic profiling and potential biomarkers, the relevant metabolic network of PMOP rats, and further to evaluate the intervention effect of Eleutheroside E (EE) against PMOP. Using multivariate statistical analysis combined with UPLC-Q/TOF-MS, a total of 27 biomarkers were identified, which related with 16 metabolic pathways, mainly involving steroidogenesis, beta oxidation of very long chain fatty acids, glutathione metabolism, carnitine synthesis, estrone metabolism, oxidation of branched chain fatty acids, etc. After treatment of EE, these biomarkers were markedly regulated, mainly involving steroid hormone biosynthesis, arachidonic acid metabolism, primary bile acid biosynthesis, indicating that EE had the therapeutic effect on PMOP. This study identified the potential urine metabolic markers and related metabolic pathways of the PMOP, explained the metabolic effect and pharmacological mechanisms of EE against PMOP, and provided a basis for the pharmacological study of EE.

The role of using different reference population in the prevalence of low BMD in the thalassemia patients

Purpose

Prevalence of osteoporosis reported as high as 50% in thalassemia major patients. We compared bone density (BMD) of our patients with results of bone densitometry of participants of a national study, to find if BMD diagnosis is ethnicity sensitive or not.

Methods

In 177 adult beta thalassemia major patients and 490 normal subjects of 20-39 y/o range, dual-energy X-ray absorptiometry of the spine and femur performed. Normal subjects participated in Iranian Multi-center Osteoporosis Study (IMOS). Mean and standard deviation of normal ones achieved and Z-score of patients re-calculated based on normal Iranians. As BMD of normal participants and patients performed by devices of different brands, analyses done based on calculated standard BMD of all participants.

Results

BMD of patients was significantly lower than normal participants (P value <0.001). Frequency of Z-score ≤-2 found in 52% and 56% of patients in femur and spine regions, respectively. New Z-score of patients according to Iranian normal populations calculated. Frequency of this new Z-score ≤-2 found in 16% and 72% of patients in femur and spine regions, respectively.

Conclusions

We think in secondary osteoporosis, may be other cut-off points, especially according to BMD of normal population of that geographical region are needed.

Association Between Forearm Bone Mineral Density and Metabolic Obesity in a Northern Chinese Population

Context: The link between obesity and bone health is controversial. Most studies classify obesity based on body mass index. However, differences in metabolic status may affect bone health. Purpose: To explore the potential relationship of metabolic obesity with forearm bone mineral density (BMD) in a northern Chinese population. Methods: This is a retrospective study involving a total of 2122 subjects divided into four groups: a metabolically healthy normal-weight (MHNW) group, a metabolically healthy obesity (MHO) group, a metabolically unhealthy, but normal-weight (MUNW) group, and a metabolically unhealthy obesity (MUO) group. Analysis of covariance was performed to compare forearm BMD among the groups. The covariates included age, weight, and height, along with menopause status in women. Partial correlation analysis and multiple linear regression models were used to explore the associations of forearm BMD with clinical parameters. Results: Young middle-aged men with MHO had significantly higher forearm BMD than those in the MUO group. In addition, forearm BMD of young middle-aged women was higher in the MHNW group than in the MUNW group. Partial correlation analysis and multiple linear regression analysis suggested that homeostasis model assessment of insulin resistance (HOMA-IR) was negatively correlated with forearm BMD in young middle-aged male subjects with MUO, and waist circumference (WC) and low-density lipoprotein cholesterol (LDL-C) showed a significant negative relationship with forearm BMD in young middle-aged female MUNW subjects. Conclusions: Men in the MUO group and women in the MUNW group were more likely to have lower forearm BMD if they were of young middle age. Metabolic obesity could be a better method for defining obesity when exploring the relationship between obesity and bone health in Chinese individuals. WC, LDL-C, and insulin resistance might be negative predictors of bone health.

Investigation of differences of sacral and vertebral bone mineral densities before and after radiotherapy in patients with locally advanced rectal cancer

PURPOSE

Radiotherapy is a treatment method performed using ionizing radiation on cancer patients either alone or with surgery and/or chemotherapy. Although modern radiotherapy techniques provide a significant advantage in protecting healthy tissues, it is inevitable that normal tissues are also located in the areas targeted by radiations. In this study, we aimed to examine the bone mineral density changes in bone structures commonly included in the irradiated area such as, L5 vertebra, sacrum, and femur heads, in patients who have received pelvic radiotherapy; and the relationship between these changes with radiation dose.

MATERIAL AND METHODS

Patients included in the study had been previously diagnosed with rectal cancer, which were operated or not. Preoperative or postoperative pelvic radiotherapy was planned for all patients. In terms of convenience when comparing with future scans, all densitometry and CT scans were performed with the same devices. Fifteen patients were included in the study. In order to determine the dose of radiation each identified area had taken after radiotherapy, the sacrum, L5 vertebra, bilateral femoral heads, and L1 regions were contoured in the CT scans in which treatment planning was done. Sagittal cross-sectional images were taken advantage of while these regions were being contoured.

RESULTS

Bone mineral density was evaluated with CT and dual-energy X-ray absorptiometry before and after the treatment. The regions that have theoretically been exposed to irradiation, such as L5, sacrum, left to right femur were found to have significant difference in terms of bone density. According to CT evaluation, there was a significant decrease in bone intensity of L5, sacrum, left and right femurs. Dual-energy X-ray absorptiometry assessment revealed that the whole of the left femoral head, left femur neck and Ward's region were significantly affected by radiotherapy. However, there was no significant difference in the sacrum and L5 vertebra before and after radiotherapy.

CONCLUSION

More accurate results could be achieved if the same study was conducted on a larger patient population, with a longer follow-up period. When the reduction in bone density is at maximum or a cure is likely in a long-term period, bone mineral density could be determined by measurements performed at regular intervals.

Discordance in diagnosis of osteoporosis by quantitative computed tomography and dual-energy X-ray absorptiometry in Chinese elderly men

Objective

The objective of this study was to investigate the diagnostic discordance of osteoporosis by quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DXA) in Chinese elderly men.

Methods

A total of 313 males older than 60 years, who underwent both spinal QCT and lumbar spine and hip DXA in our department, were included. The diagnostic criteria established by the World Health Organisation in 1994 were used for DXA to diagnose osteoporosis, and the criteria recommended by the International Society of Clinical Densitometry were used for QCT. The osteoporosis detection rate by the two techniques was calculated, and the difference was compared. The minor discordance was considered present when the different diagnostic classes between the two techniques were adjacent. Major discordance was present when the diagnosis by one technique was osteoporosis and the other was normal. The computed tomography images were reviewed by radiologists to assess whether vertebral fracture, aorta calcification or degeneration was present.

Results

In the 313 participants (mean age, 79.6 ± 7.2 years), the osteoporosis detection rate was 10.9% for DXA (lumbar spine and hip) and 45.1% for QCT, a significant difference (p < 0.001). The major discordance, minor discordance and concordance of diagnosis between the two techniques were seen in 8.3%, 50.8% and 40.9%, respectively. QCT detected osteoporosis better than DXA. The causes of this discordance were degeneration of spine, abdominal aorta calcification and vertebral fractures.

Conclusion

Our study demonstrated that discordance was common when using QCT and DXA to diagnose osteoporosis and that spinal degeneration, aorta calcification and fracture obscure the bone mineral density measurement of spine by DXA. QCT is a more sensitive method of choice to identify osteoporosis in elderly Chinese men.

The translational potential of this article

This study investigated the diagnostic discordance of osteoporosis by quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DXA) in Chinese elderly men. The results demonstrated that QCT is a more sensitive method of choice to identify osteoporosis in elderly Chinese men. This work may help clinicians make an appropriate choice of technique for the accurate diagnosis of osteoporosis and identify the patients at high risk of osteoporosis who should be treated early to prevent fractures. This may influence the therapeutic plan and the overall prognosis of patients.

Clinical utility of bone markers in various diseases

Measurements of bone markers (BMs) in peripheral blood or urine are a pivotal part of bone research within modern clinical medicine. In recent years the use of BMs increased substantially as they can be useful either to diagnose bone (related) disease and to follow its natural history, but also to monitor the effects of interventions. However, the use of BMs is still complicated mainly due to (pre)analytical variability of these substances, limited accessibility of assays, variable cut-off values in different countries and laboratories and heterogeneous results with regard to clinical implications of measuring BMs in several studies. This review will provide the clinician with a practical guide, based on current evidence, in which circumstances to test which bone markers for optimal diagnostic purposes, in order to improve patient care in different areas of bone diseases including Paget's disease, primary osteoporosis, tumor induced osteomalacia, hypophosphatemic rickets, van Buchem disease, chronic kidney disease, rheumatoid arthritis, neoplasma/multiple myeloma, type 2 diabetes mellitus and primary hyperparathyroidism. The clinician should consider fasting state, recent fractures, aging, menopausal status, concomitant liver and kidney disease when ordering and interpreting BM measurements as these factors might result in misleading BM concentrations. We found that BMs are clearly useful in the current diagnosis of tumor induced osteomalacia, van Buchem disease, Paget's disease and hypophosphatemic rickets. In addition, BMs are useful to monitor disease activity in chronic kidney disease, Paget's disease and are useful to monitor treatment adherence in osteoporosis.

Oxidative stress induces imbalance of adipogenic/osteoblastic lineage commitment in mesenchymal stem cells through decreasing SIRT1 functions

With rapidly ageing populations worldwide, the incidence of osteoporosis has reached epidemic proportions. Reactive oxygen species (ROS), a by‐product of oxidative stress and ageing, has been thought to induce osteoporosis by inhibiting osteogenic differentiation of mesenchymal stem cells (MSCs). However, specific mechanisms of how ROS results in alterations on MSC differentiation capacity have been inconsistently reported. We found that H₂O₂, an ROS, simultaneously induced MSC lineage commitment towards adipogenesis and away from osteogenesis at the functional as well as transcriptional level. In addition, H₂O₂ decreased the activities of SIRT1, a histone deacetylase and longevity gene. By silencing and reconstituting SIRT1 in MSCs, we demonstrated that H₂O₂ exerted its disparate effects on adipogenic/osteoblastic lineage commitment mainly through modulating SIRT1 expression levels. Treatment with resveratrol, a SIRT1 agonist, can also reverse this ROS‐induced adipogenesis/osteogenesis lineage imbalance. Moreover, SIRT1 regulation of RUNX2 transcriptional activity was mediated through deacetylation of the ROS‐sensitive transcription factor FOXO3a. Taken together, our data implicate SIRT1 as playing a vital role in ROS‐directed lineage commitment of MSCs by modulating two lineages simultaneously. Our findings on the critical role of SIRT1 in ROS/age‐related perturbations of MSC differentiation capacity highlight this molecule as a target for maintenance of MSC stemness as well as a potential anabolic target in osteoporosis.

Efficacy of radiographic density values of the first and second cervical vertebrae recorded by CBCT technique to identify patients with osteoporosis and osteopenia

Background. Osteoporosis is a systemic skeletal disease characterized by a decrease in bone strength with an increase in the risk of fractures. This study aimed at evaluating the ability to predict osteoporosis and osteopenia based on radiographic density values obtained from CBCT imaging technique. Methods. CBCT images of 108 patients were prepared by using NewTom VGI (QR, Verona, Italy). Then the patients were assigned to osteoporosis, osteopenia and healthy group, using the T-score derived from the DEXA technique. Finally, RD of the lateral mass of C1 on the left and right sides and body and dens of the C2 were measured. RD values were compared between the three groups by one-way ANOVA, followed by an appropriate post hoc test. Results. The results of the comparisons of RD values at the first and second cervical vertebrae in the three groups showed that all the values had statistically significant differences (P<0.05). The most precise diagnosis of osteoporosis was related to the RD values of the body of C2 and left lateral mass of C1 that was equal to 99% and their cut-off points were 375 and 386, respectively. Conclusion. Based on the findings of this study, it is possible to predict the osteoporosis status of the patient through the RD related to the body of C2 and the left lateral mass of C1 more accurately than the other areas.

Osteoporosis following heart transplantation and immunosuppressive therapy

Heart transplantation (HT) remains the ultimate final therapy for patients with end-stage heart failure, who despite optimal medical and surgical treatments exhibit severe symptoms. To prevent rejection of the transplanted organ, HT patients require life-long immunosuppressive therapy. The goal of the immunosuppression is to minimise the risk of immune-mediated graft rejection, while avoiding clinical side-effects. Current immunosuppressive agents have yielded good survival outcome, however, complications of the immunosuppressive therapy, such as impaired bone strength and increased fracture risk, are common among HT patients rendering increased morbidity and mortality rates. The main aim of the present review was to summarise current knowledge on bone strength impairment after HT and concomitant immunosuppressive therapy.

Knowledge on Osteoporosis among Nurses

BACKGROUND

It is crystal clear how important healthcare providers are well-aware of reasonable knowledge on osteoporosis, because they are at the forefront of such management. However, no study has been yet assessed in the knowledge on osteoporosis among healthcare providers particularly in nurse. Therefore, we evaluated the knowledge on osteoporosis of nurses.

METHODS

In April 2017, 67 nurses were evaluated using a modified Facts on Osteoporosis Quiz (FOOQ).

RESULTS

Although nurses grasped some points of osteoporosis, their knowledge was insufficient concerning effects of weight, physical exercise and calcium intake during adolescence.

CONCLUSIONS

The level of knowledge on osteoporosis was evaluated in nurses, and the effect of weight, physical exercise, and calcium intake during adolescence should be focused in an educational program on osteoporosis for nurses.

Pelvic insufficiency fracture (PIF) incidence in patients treated with intensity-modulated radiation therapy (IMRT) for gynaecological or anal cancer: single-institution experience and review of the literature

OBJECTIVE

To summarize the results of pelvic insufficiency fracture (PIF) incidence in patients with anal or gynaecological cancer treated by pelvic intensity-modulated radiation therapy (IMRT).

METHODS

The clinical and morphological (CT and/or pelvic MRI) characteristics of patients treated by IMRT at our institution between 2007 and 2014 were analyzed. The global incidence of PIF after external beam radiotherapy and the impact of tumour site (gynaecological or anal cancer) were determined. A dosimetric study was then performed to compare patients with and without pelvic fracture.

RESULTS

341 patients were treated by IMRT for gynaecological or anal cancer between 2007 and 2014. 15 patients experienced at least 1 pelvic fracture after external beam radiotherapy, corresponding to an overall incidence of 4.4%. Age and menopausal status were correlated with an increased fracture risk (p = 0.0274 and p < 0.0001, respectively). The site of the primary tumour (gynaecological or anal canal) was not associated with an excess fracture risk. The median maximum dose received at the fracture site was 50.3 Gy (range: 40.8-68.4 Gy).

CONCLUSION

The incidence of pelvic fracture after IMRT is low, but is higher after the age of 50 and in patients who are postmenopausal. Pre-treatment evaluation of bone density by bone densitometry and phosphorus-calcium assessment could be useful prior to the management of these patients. Advances in knowledge: Pelvic fractures are a frequent complication after radiotherapy. The influence of IMRT and clinical characteristics were evaluated in this study.

Postmenopausal osteoporosis

Osteoporosis is a metabolic bone disorder that is characterized by low bone mass and micro-architectural deterioration of bone tissue. Fractures of the proximal femur, the vertebrae and the distal radius are the most frequent osteoporotic fractures, although most fractures in the elderly are probably at least partly related to bone fragility. The incidence of fractures varies greatly by country, but on average up to 50% of women >50 years of age are at risk of fractures. Fractures severely affect the quality of life of an individual and are becoming a major public health problem owing to the ageing population. Postmenopausal osteoporosis, resulting from oestrogen deficiency, is the most common type of osteoporosis. Oestrogen deficiency results in an increase in bone turnover owing to effects on all types of bone cells. The imbalance in bone formation and resorption has effects on trabecular bone (loss of connectivity) and cortical bone (cortical thinning and porosity). Osteoporosis is diagnosed using bone density measurements of the lumbar spine and proximal femur. Preventive strategies to improve bone health include diet, exercise and abstaining from smoking. Fractures may be prevented by reducing falls in high-risk populations. Several drugs are licensed to reduce fracture risk by slowing down bone resorption (such as bisphosphonates and denosumab) or by stimulating bone formation (such as teriparatide). Improved understanding of the cellular basis for osteoporosis has resulted in new drugs targeted to key pathways, which are under development.

Role of ginsenosides, the main active components of Panax ginseng, in inflammatory responses and diseases

Panax ginseng is one of the most universally used herbal medicines in Asian and Western countries. Most of the biological activities of ginseng are derived from its main constituents, ginsenosides. Interestingly, a number of studies have reported that ginsenosides and their metabolites/derivatives—including ginsenoside (G)-Rb1, compound K, G-Rb2, G-Rd, G-Re, G-Rg1, G-Rg3, G-Rg5, G-Rh1, G-Rh2, and G-Rp1—exert anti-inflammatory activities in inflammatory responses by suppressing the production of proinflammatory cytokines and regulating the activities of inflammatory signaling pathways, such as nuclear factor-κB and activator protein-1. This review discusses recent studies regarding molecular mechanisms by which ginsenosides play critical roles in inflammatory responses and diseases, and provides evidence showing their potential to prevent and treat inflammatory diseases.

Impacts of Ultra-early Hyperbaric Oxygen Therapy on Bone Mass of Rats With Complete Spinal Cord Transection

STUDY DESIGN

Seventy-five SD rats were randomly assigned to four groups: sham-operated group (Sham, n = 15), complete spinal cord transection (CSCT, n = 20) group, hyperbaric oxygenation group 1 (HBO1, n = 20), and hyperbaric oxygenation group 2 (HBO2, n = 20).

OBJECTIVE

The aim of this study was to analyze the impacts of ultra-early hyperbaric oxygen therapy on bone mass of rats with CSCT.

SUMMARY OF BACKGROUND DATA

Treatment of patients with complete SCI is still an unresolved medical issue and needs to be further investigated. Studies on changes in bone mass as well as osteoporosis prevention after SCI have important clinical significance.

METHODS

Rats in the sham group only underwent T10 laminectomy, without damaging the spinal cord. Rats in CSCT, HBO1, and HBO2 groups underwent T10 laminectomy and spinal cord transection at T10 level. Rats in HBO1 and HBO2 groups received three courses of hyperbaric oxygen therapy with 10 days per course starting at 3 and 12 hours after spinal cord injury, respectively. The femoral biomechanical characteristics, the bone calcium, and the bone hydroxyproline (B-HYP) contents were determined. Morphology of the femur bone trabecula and the bone collagen were observed by HE staining and by masson triad color staining, respectively.

RESULTS

After 6 weeks of treatment, rats in the CSCT group showed significant decreases in femur structural and material mechanics parameters, calcium and B-HYP contents, (P < 0.01), as well as sparse, fractured, malaligned trabecular bone and collagen compared with rats in the sham group. After treatments, compared with rats in the CSCT and HBO2 groups, rats in HBO1 group showed enhancement in femur structural and material mechanics parameters, calcium and B-HYP contents, (P < 0.05), as well as trabecular bone and collagen with better continuity and neater arrangement.

CONCLUSION

Ultra-early HBO therapy can significantly improve bone mass in CSCT rats.

LEVEL OF EVIDENCE

N/A.

Self-assembling bisphosphonates into nanofibers to enhance their inhibitory capacity on bone resorption

Osteoporosis (OP) is an important aging-related disease and the effective prevention/treatment of this disease remains challenging. Considering the acidic microenvironment of bone resorption lacunae, herein, we rationally designed two pamidronate (Pami)-derivative and alendronate (Alen)-derivative hydrogelators and which self-assemble into nanofibers to form supramolecular hydrogels under acidic conditions. Cell viability assay, osteoclastogenesis, osteoclastic gene expression, and in vitro bone resorption results indicated that both and have better inhibitory effects on osteoclastic formation and bone resorption than Pami and Alen, respectively. We anticipate that our new drugs and could "smartly" self-assemble and locally concentrate the drugs at bone resorption lacunae in vivo and subsequently prevent/treat osteoporosis more efficiently.

For the first fracture to be the last

Increased longevity has made progression in the number of fractures increasingly significant. Because hip fractures give rise to high morbidity and mortality rates and have high treatment costs, their occurrence is the most important marker of effectiveness in relation to osteoporosis treatment. In countries and systems that, especially over the last decade, have been investing in the prevention of osteoporosis and its consequences, the number of hip fractures has been decreasing. What these countries have in common is secondary prevention of fractures, i.e. to avoid subsequent fractures. Given that half of the patients who present hip fractures have had a previous fracture and that the treatments available have proven to be extremely efficient for decreasing subsequent fractures, a good proportion of hip fractures are preventable. It is within this scenario that orthopedists play a leading role.

Contribution of Lumbar Spine BMD to Fracture Risk in Individuals With T-Score Discordance

Fracture risk estimates are usually based on femoral neck (FN) BMD. It is unclear how to address T-score discordance, where lumbar spine (LS) T-score is lower than FN T-score. The objective of this work was to examine the impact of LS BMD on fracture risk, in individuals with lower LS T-score than FN T-score. Participants aged 60+ years from the Dubbo Osteoporosis Epidemiology Study with LS and FN BMD measured at first visit, and were followed from 1989 to 2014. Five-hundred and seventy-three (573) of 2270 women and 131 of 1373 men had lower LS than FN T-score by ≥ 0.6 standard deviation (SD) (low-LS group based on least significant change). In low-LS women, each 1 SD lower LS T-score than FN was associated with a 30% increase in fracture risk (hazard ratio [HR] 1.30; 95% CI, 1.11 to 1.45). For low-LS men there was a 20% nonsignificant increase in fracture risk for each 1 SD lower LS than FN T-score (HR 1.20; 95% CI, 0.10 to 1.67). Low-LS women had greater absolute fracture risks than the rest of the women. This increased risk was more apparent for lower levels of FN T-score and in older age groups. At an FN T-score of -2, low-LS women had a 3%, 10%, and 23% higher 5-year absolute fracture risk than non-low LS women in the 60 to 69 year, 70 to 79 year, and 80+ years age-groups, respectively. Furthermore, an osteoporotic LS T-score increased 5-year absolute fracture risk for women with normal or osteopenic FN T-score by 10% to 13%. Men in the low-LS group had very few fractures; therefore, a meaningful analyses of fracture risk could not be conducted. This study shows the significant contribution of lower LS BMD to fracture risk over and above FN BMD in women. A LS BMD lower than FN BMD should be incorporated into fracture risk calculators at least for women in older age-groups.

The role of glucuronidation in drug resistance

The final therapeutic effect of a drug candidate, which is directed to a specific molecular target strongly depends on its absorption, distribution, metabolism and excretion (ADME). The disruption of at least one element of ADME may result in serious drug resistance. In this work we described the role of one element of this resistance: phase II metabolism with UDP-glucuronosyltransferases (UGTs). UGT function is the transformation of their substrates into more polar metabolites, which are better substrates for the ABC transporters, MDR1, MRP and BCRP, than the native drug. UGT-mediated drug resistance can be associated with (i) inherent overexpression of the enzyme, named intrinsic drug resistance or (ii) induced expression of the enzyme, named acquired drug resistance observed when enzyme expression is induced by the drug or other factors, as food-derived compounds. Very often this induction occurs via ligand binding receptors including AhR (aryl hydrocarbon receptor) PXR (pregnane X receptor), or other transcription factors. The effect of UGT dependent resistance is strengthened by coordinate action and also a coordinate regulation of the expression of UGTs and ABC transporters. This coupling of UGT and multidrug resistance proteins has been intensively studied, particularly in the case of antitumor treatment, when this resistance is "improved" by differences in UGT expression between tumor and healthy tissue. Multidrug resistance coordinated with glucuronidation has also been described here for drugs used in the management of epilepsy, psychiatric diseases, HIV infections, hypertension and hypercholesterolemia. Proposals to reverse UGT-mediated drug resistance should consider the endogenous functions of UGT.

Osteoporosis: Its Prosthodontic Considerations - A Review

Osteoporosis is a disease of bone which is common in middle aged post-menopausal women. The osteoporotic bones will become weak and are prone to fractures. Osteoporosis means "porous bone" is a "silent disease". Healthy bone microscopically appears like a honeycomb but, in osteoporotic patients the spaces are much bigger. The osteoporotic bone will have less density or mass and the structure of bone tissue is abnormal. As the bone becomes less dense, they become weaker and more likely to fracture. Women are four times more likely to develop osteoporosis than men. Oral health maintenance for adults with osteoporosis is important. Bone weakness and loss may also affect the ridges that hold dentures resulting in poor fitting dentures. The patients require new dentures more often than those who have strong, healthy bones. Best way to handle problems is avoid delaying or postponing the dental treatment. Regular dental visits and healthy lifestyle is necessary in strengthening and maintenance of good bone health. Well balanced diet with high amounts of vitamin-D & calcium with regular physical activity is recommended.

Persistence with denosumab and persistence with oral bisphosphonates for the treatment of postmenopausal osteoporosis: a retrospective, observational study, and a meta-analysis

The objectives of this study were to estimate persistence with denosumab and put these results in context by conducting a review of persistence with oral bisphosphonates. Persistence with denosumab was found to be higher than with oral bisphosphonates.

PURPOSE

This study had two objectives: to analyse persistence in Swedish women initiating denosumab for treatment of postmenopausal osteoporosis (PMO) and to put these findings in context by conducting a literature review and meta-analysis of persistence data for oral bisphosphonates.

METHODS

The study used the Swedish Prescribed Drug Register and included women aged at least 50 years initiating denosumab between May 2010 and July 2012. One injection of denosumab was defined as 6-month persistence. Women were considered persistent for another 6 months if they filled their next prescription within 6 months + 56 days and survival analysis applied to the data. A literature search was conducted in PubMed to identify retrospective studies of persistence with oral bisphosphonates and pooled persistence estimates were calculated using a random-effects model.

RESULTS

The study identified 2,315 women who were incident denosumab users. Mean age was 74 years and 61% had been previously treated for PMO. At 12 and 24 months, persistence with denosumab was 83% (95% CI, 81-84%) and 62% (95% CI, 60-65%), respectively. The literature search identified 40 articles for inclusion in the meta-analysis. At 12 and 24 months, persistence with oral bisphosphonates ranged from 10% to 78% and from 16% to 46%, with pooled estimates of 45% and 30%, respectively.

CONCLUSION

These data from the Swedish Prescribed Drug Register and literature review suggest that persistence was higher with denosumab than with oral bisphosphonates.

Notoginsenoside R1 stimulates osteogenic function in primary osteoblasts via estrogen receptor signaling

Notoginsenoside R1 (NGR1), a novel phytoestrogen isolated from Panax notoginseng, has been widely used in the treatment of microcirculatory diseases in Asian countries. Here we investigated the effect of NGR1 on osteoblast differentiation and mineralization process. Furthermore, we also evaluated NGR1's estrogenic properties, especially its effects on estrogen receptors (ERs). NGR1 activated the transcriptional activity of phosphorylated estrogen response element (pERE)-luciferase (Luc) and induced ERα phosphorylation in hBMSC. In addition, ER activation correlated with induction and was associated with osteoblast differentiation biomarkers including alkaline phosphatase activity and transcription of osteoblastic genes, e.g., type I collagen (COL1), osteonectin, osteocalcin (OC), runt related protein 2 (Runx2), and osterix. NGR1 also promoted the mineralization process of osteoblasts. The NGR1-induced effects were confirmed to be mediated by the ER by the observation that pretreatment of the osteoblasts with the ER antagonist, ICI 182,780 fully blocked the effects. Our results showed that NGR1 stimulates osteogenic differentiation of cultured osteoblasts by activating ER signaling and in turn might be a potential therapeutic alternative for the prevention and treatment of osteoporosis.

What is the optimal bone-preserving strategy for patients with Addison's disease?

Addison's disease is associated with low bone mineral density and increased risk of hip fractures. Causes are multifactorial, contributed by underlying adrenocortical hormonal deficiency, associated autoimmune endocrinopathies, electrolyte disturbances and, in some patients, supraphysiologic glucocorticoid replacement. Recent realization of physiologic cortisol production rate has revised downwards glucocorticoid replacement dosages. Meanwhile, new research has emerged suggesting complex interplay between sodium and calcium homoeostasis under the influence of mineralocorticoid and parathyroid hormone that may impact bone health. As the prevalence of Addison's disease is rising, and osteoporosis and fractures are associated with significant morbidity and increased mortality, attention to bone preservation in Addison's disease is of clinical relevance and importance. We suggest an approach to bone health in Addison's disease integrating physiologic adrenocortical hormonal replacement with electrolyte and mineral homoeostasis optimization.

Bone densitometry

Dual-energy x-ray absorptiometry (DXA) is the method of choice to measure bone mineral density in elderly patients and others at risk for osteoporosis. Early detection is important because fractures represent an enormous health burden. In this article, the authors discuss the application and interpretation of DXA scans as well as limitations and conditions that can affect results.

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.