Diagnosis and epidemiology of osteoporosis

Risk analysis for subsequent fracture of osteoporotic fractures in Chinese women over age 60: a nationwide cross-sectional study

Prevention of subsequent fracture is a major public health challenge in the field of osteoporosis prevention and treatment, and older women are at high risk for osteoporotic fractures. This study aimed to examine factors associated with subsequent fracture in older Chinese women with osteoporosis. We collected data on 9212 older female patients with osteoporotic fractures from 580 medical institutions in 31 provinces of China. Higher odds of subsequent fractures were associated with age of 70-79 years (OR 1.218, 95% CI 1.049-1.414), age ≥ 80 (OR 1.455, 95% CI 1.222-1.732), index fracture site was vertebrae (OR 1.472, 95% CI 1.194-1.815) and hip (OR 1.286, 95% CI 1.041-1.590), index fracture caused by fall (OR 1.822, 95% CI 1.281-2.591), strain (OR 1.587, 95% CI 1.178-2.139), no inducement (OR 1.541, 95% CI 1.043-2.277), and assessed as high risk of fracture (OR 1.865, 95% CI 1.439-2.416), BMD T-score ≤ -2.5 (OR 1.725, 95% CI 1.440-2.067), history of surgery (OR 3.941, 95% CI 3.475-4.471) and trauma (OR 8.075, 95% CI 6.941-9.395). Low risk of fall (OR 0.681, 95% CI 0.513-0.904), use of anti-osteoporosis medication (AOM, OR 0.801, 95% CI 0.693-0.926), and women who had received fall prevention health education (OR 0.583, 95% CI 0.465-0.730) associated with lower risk. The areas under the curve of the prediction model was 0.818. The sensitivity was 67.0% and the specificity was 82.0%. The prediction model showed a good ability to predict the risk of subsequent fracture in older women with osteoporotic fractures and are suitable for early self-measurement which may benefit post-fracture management.

Efficacy and Safety of Annual Infusion of Zoledronic Acid and Weekly Oral Alendronate in the Treatment of Primary Osteoporosis: A Meta-Analysis

This systematic review and meta-analysis aimed to reveal the efficacy and safety of zoledronic acid compared with alendronate in patients with primary osteoporosis. The PubMed, Embase, and the Cochrane Library databases were searched from the establishment of each database to April 2022 for comparative studies on the topic, including randomized controlled trials (RCTs) and cohort studies, and 2 authors individually extracted information and data concerning study design, baseline characteristics, bone mineral density (BMD), bone turnover markers, and adverse events (AEs). We identified 8 eligible trials, including 1863 participants. Pooled estimates demonstrated that, compared with alendronate, zoledronic acid showed no significant difference in increasing the BMD of the lumbar spine after 1 year (SMD = -0.03, 95%CI -0.15 to 0.09, I²  = 0.41%) or after 2 years (SMD = 0.16, 95%CI -0.12 to 0.43, I²  = 63%), and the BMD of the total hip after 1 year (SMD = -0.08, 95%CI -0.31 to 0.14, I²  = 64%) or after 2 years (SMD = 0.05, 95%CI -0.21 to 0.32, I²  = 61%). No significant difference in improving bone turnover markers, including serum C-terminal cross-linking telopeptide of type-1 collagen, urine N-terminal cross-linking telopeptide of type-1 collagen, and serum procollagen type-1 N-terminal propeptide, were found, whereas significantly higher total AE rates (RR = 2.27, 95%CI 1.60 to 3.21, I²  = 75%) were recorded within 3 days of infusion, but some lower AE rates, particularly of gastrointestinal AEs (RR = 0.6, 95%CI 0.44 to 0.83, I²  = 37%), were noted after 3 days of infusion. Compared with alendronate, zoledronic acid has achieved comparable therapeutic results in the treatment of primary osteoporosis in increasing BMD and reducing bone turnover marker levels. Zoledronic acid showed a better safety profile than alendronate with long-term use, especially with regards to gastrointestinal-related AEs.

Evaluation of tissue in repair with natural latex and / or hyaluronic acid in surgical bone defects

This study evaluated the bone repair in surgical defects of rats treated with hyaluronic acid (HA) associated or not with Hevea brasiliensis fraction protein (F-1). Bone defect were created in 15 albino Wistar rats divided into 3 groups (n=5): Control group (1) - blood clot; HA group (2) - 0.5% hyaluronic acid; HAF1 group (3) - 0.1% F-1 protein fraction dissolved in 0.5% hyaluronic acid. After 4 weeks, the animals were euthanized and the bone repair was evaluated through histomorphometric analysis, zymography and immunohistochemistry. The neoformed bone area did not show a significant difference (p = 0.757), but there was a tendency for bone trabeculation to increase in the groups HA and HAF1. For immunohistochemically analysis, there was a difference in vascular endothelial growth factor (VEGF) labeling (p = 0.023), being higher in the groups HA and HAF1 than the control group. No significant difference in bone sialoprotein (BSP) (p = 0.681), osteocalcin (p = 0.954), however, significant difference in platelet endothelial cell adhesion molecule-1 (CD-31) (p = 0.040), with HAF1 group being significantly lower than the control. For zymographic analysis, there was no significant difference for metalloproteinase-2 (MMP-2) (p = 0.068), but there was a tendency to increase MMP-2 in the HA group. Despite the influence on angiogenic factors and the apparent tendency for greater trabeculation in the HA and HAF1 groups, there was no significant difference in the area of ​​newly formed bone tissue in the analyzed period.

Pre-Clinical Models in Implant Dentistry: Past, Present, Future

Biomedical research seeks to generate experimental results for translation to clinical settings. In order to improve the transition from bench to bedside, researchers must draw justifiable conclusions based on data from an appropriate model. Animal testing, as a prerequisite to human clinical exposure, is performed in a range of species, from laboratory mice to larger animals (such as dogs or non-human primates). Minipigs appear to be the animal of choice for studying bone surgery around intraoral dental implants. Dog models, well-known in the field of dental implant research, tend now to be used for studies conducted under compromised oral conditions (biofilm). Regarding small animal models, research studies mostly use rodents, with interest in rabbit models declining. Mouse models remain a reference for genetic studies. On the other hand, over the last decade, scientific advances and government guidelines have led to the replacement, reduction, and refinement of the use of all animal models in dental implant research. In new development strategies, some in vivo experiments are being progressively replaced by in vitro or biomaterial approaches. In this review, we summarize the key information on the animal models currently available for dental implant research and highlight (i) the pros and cons of each type, (ii) new levels of decisional procedures regarding study objectives, and (iii) the outlook for animal research, discussing possible non-animal options.

Efficacy of risedronate with cholecalciferol on bone mineral density in Korean patients with osteoporosis

The efficacy of once-weekly risedronate with and without cholecalciferol in bone mineral density (BMD) in Korean patients with osteoporosis was compared. After 12 months, both spine and hip BMD increased significantly in both groups, but there was no significant difference between two groups.

INTRODUCTION

This study investigated the efficacy and safety of once-weekly risedronate with and without cholecalciferol in BMD in Korean patients with osteoporosis.

METHODS

This was a prospective, 12-month, randomized, open-labeled, actively controlled trial involving 41 hospitals. A total of 841 subjects with osteoporosis were randomized to once-weekly risedronate (35 mg) and cholecalciferol (5600 IU) in a single pill (RSD+, n = 642) or once-weekly risedronate (35 mg) alone (RSD, n = 199). BMD was measured via dual-energy X-ray absorptiometry at the lumbar spine and hip, and the serum levels of 25-hydroxy vitamin D (25(OH) D), parathyroid hormone (PTH), and alkaline phosphatase (ALP) were assayed at baseline and after 12 months of treatment.

RESULTS

After 12 months, the lumbar spine, femoral neck, and total hip BMD increased significantly in both groups; there was no significant difference between two groups. Women in the RSD+ group exhibited significantly increased lumbar spine BMD, and subjects with previous fracture history in the RSD+ group had significantly increased total hip BMD compared with the RSD group. The serum 25(OH) D level increased significantly in the RSD+ group. The serum PTH level decreased in the RSD+ group but increased in the RSD group. The serum ALP level significantly decreased in both groups; there was no significant difference between two groups.

CONCLUSIONS

A once-weekly pill containing risedronate and cholecalciferol had the equivalent antiresorptive efficacy on BMD compared with risedronate alone and improved 25(OH) D serum levels after 12 months of treatment without significant adverse events in Korean patients with osteoporosis.

Improving the Hip Fracture Risk Prediction Through 2D Finite Element Models From DXA Images: Validation Against 3D Models

Osteoporotic fracture incidence represents a major social and economic concern in the modern society, where the progressive graying of the population involves an highly increased fracture occurrence. Although the gold standard to diagnose osteoporosis is represented by the T-score measurement, estimated from the Bone Mineral Density (BMD) using Dual-energy X-ray Absorptiometry (DXA), the identification of the subjects at high risk of fracture still remains an issue. From this perspective, the purpose of this work is to investigate the role that DXA-based two-dimensional patient-specific finite element (FE) models of the proximal femur, in combination with T-score, could play in enhancing the risk of fracture estimation. With this aim, 2D FE models were built from DXA images of the 28 post-menopausal female subjects involved. A sideways fall condition was reproduced and a Risk of Fracture (RF^) was computed on the basis of principal strains criteria. The identified RF^ was then compared to that derived from the CT-based models developed in a previous study. The 2D and 3D RF^ turned out to be significantly correlated (Spearman's ρ = 0.66, p < 0.001), highlighting the same patients as those at higher risk. Moreover, the 2D RF^ resulted significantly correlated with the T-score (Spearman's ρ = −0.69, p < 0.001), and managed to better differentiate osteopenic patients, drawing the attention to some of them. The Hip Structural Analysis (HSA) variables explaining the majority of the variance of the 2D and 3D fracture risk were the same as well, i.e., neck-shaft angle and narrow neck buckling ratio. In conclusion, DXA-based FE models, developable from currently available clinical data, appear promising in supporting and integrating the present diagnostic procedure.

Is there any association between osteoporotic vertebral fracture and vitamin K epoxide reductase complex subunit-1 polymorphism in Turkish society? A pilot study

OBJECTIVE

In this study, the relationship between osteoporotic vertebral fractures and 9041 Guanine/Adenine and 3673 Guanine/Adenine polymorphisms related to the vitamin K epoxide reductase complex subunit-1 (VKORC1) gene in postmenopausal women with osteoporosis was investigated.

METHOD

DNA was isolated from blood samples collected from 150 women with postmenopausal osteoporosis. Genotyping of the two polymorphic regions (9041 Guanine/Adenine and 3673 Guanine/Adenine) in VKORC1 was performed using polymerase chain reaction-restriction fragment length polymorphism analysis. The presence of radiographic fractures among the 150 patients was ascertained by using the Genant method.

RESULT

At least one fracture was detected in 98 patients, and no fracture was observed in 52 patients on radiological images. We found no association between the 9041 Guanine/Adenine (p=0.283) and 3673 Guanine/Adenine (p=0.232) polymorphisms of the VKORC1 gene and the development of secondary postosteoporotic fractures in our study.

CONCLUSION

There was no relationship between osteoporotic vertebral fracture and VKORC1 gene polymorphism in a postmenopausal Turkish population.

Effects of tocotrienol from Bixa orellana (annatto) on bone histomorphometry in a male osteoporosis model induced by buserelin

INTRODUCTION

Osteoporosis is a debilitating skeletal side effect of androgen deprivation therapy based on gonadotropin-releasing hormone (GnRH) agonist in men. Tocotrienol from Bixa orellana (annatto) has been demonstrated to offer protection against osteoporosis by exerting anabolic effects on bone. Thus, it may prevent osteoporosis among GnRH agonist users.

OBJECTIVE

This study aimed to determine the effectiveness of annatto-tocotrienol on the bone turnover markers and bone histomorphometry in a model of male osteoporosis induced by buserelin (a GnRH agonist).

METHODS

Forty-six three-months-old male Sprague-Dawley rats (three months old; 300-350 g) were randomly divided into six groups. The baseline control group (n = 6) was sacrificed at the onset of the study. The normal control group (n = 8) received corn oil (the vehicle of tocotrienol) orally daily and normal saline (the vehicle of buserelin) subcutaneously daily. The buserelin control (n = 8) received corn oil orally daily and subcutaneous buserelin injection 75 μg/kg/day daily. The calcium control (n = 8) received 1% calcium in drinking water and subcutaneous buserelin injection 75 μg/kg/day. The remaining rats were treated with two different treatments, i.e., (1) oral annatto tocotrienol at 60 mg/kg/day plus subcutaneous buserelin injection 75 μg/kg/day (n = 8); (2) oral annatto tocotrienol at 100 mg/kg/day plus subcutaneous buserelin injection 75 μg/kg/day (n = 8). The rats were injected with calcein twice before being sacrificed to label the bones. The rats were euthanized, and their blood and right femur were harvested at the end of the treatment for bone turnover markers and bone histomorphometry examination.

RESULTS

Both serum osteocalcin and C-telopeptide of type 1 collagen were not significantly different between treated groups and buserelin control (P > 0.05). The buserelin control group had a significantly lower bone volume and higher eroded surface compared with the normal control group (P < 0.05). Both groups treated with annatto tocotrienol (60 mg/kg/day and 100 mg/kg/day) had significantly higher bone volume, trabecular thickness and osteoblast number, as well as a significantly lower single-labelled surface compared with the buserelin control (P < 0.05). Only rats treated with annatto tocotrienol 60 mg/kg/day had a significantly higher double-labelled surface compared with buserelin control (P < 0.05).

CONCLUSION

Annatto tocotrienol can prevent trabecular bone loss by increasing the mineralising surface and osteoblasts number. Thus, it has a potential role in preventing bone loss in men using GnRH agonist.

Animal models for glucocorticoid-induced postmenopausal osteoporosis: An updated review

Glucocorticoid-induced postmenopausal osteoporosis is a severe osteoporosis, with high risk of major osteoporotic fractures. This severe osteoporosis urges more extensive and deeper basic study, in which suitable animal models are indispensable. However, no relevant review is available introducing this model systematically. Based on the recent studies on GI-PMOP, this brief review introduces the GI-PMOP animal model in terms of its establishment, evaluation of bone mass and discuss its molecular mechanism. Rat, rabbit and sheep with their respective merits were chosen. Both direct and indirect evaluation of bone mass help to understand the bone metabolism under different intervention. The crucial signaling pathways, miRNAs, osteogenic- or adipogenic- related factors and estrogen level may be the predominant contributors to the development of glucocorticoid-induced postmenopausal osteoporosis.

Randomized trial comparing efficacies of zoledronate and alendronate for improving bone mineral density and inhibiting bone remodelling in women with post-menopausal osteoporosis

WHAT IS KNOWN AND OBJECTIVE

Bisphosphonates are the first-line medications for treating osteoporosis. The aim of our prospective study was to compare the efficacy of zoledronate with that of alendronate in women with post-menopausal osteoporosis based on the evaluations of bone mineral density (BMD) and serum levels of biochemical markers of bone remodelling.

METHODS

Chinese women with post-menopausal osteoporosis were randomly assigned to the zoledronate (n = 52) or alendronate (n = 53) group, and were treated with 5 mg zoledronate intravenously once per year and 70 mg alendronate orally once per week, respectively. During a 3-year follow-up period, the lumbar spine, femoral neck and total hip were examined using dual-energy x-ray absorptiometry every 12 months to assess BMD, and the serum levels of amino-terminal propeptide of type I procollagen (P1NP) and carboxy-terminal cross-linked telopeptides of type 1 collagen (CTX) were measured to evaluate bone formation and resorption, respectively.

RESULTS AND DISCUSSION

Greater increases in BMD occurred in the zoledronate group over the 3-year follow-up period, with increases in BMD of 41·3%, 13·5% and 20·0% at the lumbar spine, femoral neck and total hip, respectively, compared with 16·9%, 5·88% and 8·93% in the alendronate group, respectively (P < 0·05 for all). At the 3-year follow-up, P1NP and β-CTX levels were reduced by 42·1% and 50·5% in the zoledronate group, respectively, whereas the levels of each were reduced by 19·5% and 19·4% in the alendronate group, respectively (P < 0·05 for all).

WHAT IS NEW AND CONCLUSIONS

Once yearly zoledronate administered intravenously was more efficacious for improving BMD and reducing the serum levels of P1NP and β-CTX in Chinese women with post-menopausal osteoporosis than alendronate administered orally once per week. The incidence of adverse events after the second and third zoledronate treatments was substantially lower than that in the alendronate group, suggesting a substantially lower risk of adverse events with long-term use of zoledronate in Chinese women, compared with that of alendronate use.

Second fractures among older adults in the year following hip, shoulder, or wrist fracture

We report on second fracture occurrence in the year following a hip, shoulder or wrist fracture using insurance claims. Among 273,330 people, 4.3 % had a second fracture; risk did not differ by first fracture type. Estimated adjusted second fracture probabilities may facilitate population-based evaluation of secondary fracture prevention strategies.

INTRODUCTION

The purpose of this study was estimate second fracture risk for the older US population in the year following a hip, shoulder, or wrist fracture.

METHODS

Observational cohort study of Medicare fee-for-service beneficiaries with an index hip, shoulder, or wrist fragility fracture in 2009. Time-to-event analyses using Cox proportional hazards models to characterize the relationship between index fracture type (hip, shoulder, wrist) and patient factors (age, gender, and comorbidity) on second fracture risk in the year following the index fracture.

RESULTS

Among 273,330 individuals with fracture, 11,885 (4.3 %) sustained a second hip, shoulder or wrist fracture within one year. Hip fracture was most common, regardless of the index fracture type. Comparing adjusted second fracture risks across index fracture types reveals that the magnitude of second fracture risk within each age-comorbidity group is similar regardless of the index fracture. Men and women face similar risks with frequently overlapping confidence intervals, except among women aged 85 years or older who are at greater risk.

CONCLUSIONS

Regardless of index fracture type, second fractures are common in the year following hip, shoulder or wrist fracture. Secondary fracture prevention strategies that take a population perspective should be informed by these estimates which take competing mortality risks into account.

Different reference BMDs affect the prevalence of osteoporosis

The T score represents the degree of deviation from the peak bone mineral density (BMD) (reference standard) in a population. Little has been investigated concerning the age at which the BMD reaches the peak value and how we should define the reference standard BMD in terms of age ranges. BMDs of 9,800 participants were analyzed from the Korean National Health and Nutrition Examination Survey database. Five reference standards were defined: (1) the reference standard of Japanese young adults provided by the dual-energy X-ray absorptiometry machine manufacturer, (2) peak BMD of the Korean population evaluated by statistical analysis (second-order polynomial regression models), (3) BMD of subjects aged 20-29 years, (4) BMD of subjects aged 20-39 years, and (5) BMD of subjects aged 30-39 years. T-scores from the five reference standards were calculated, and the prevalence of osteoporosis was evaluated and compared for males and females separately. The peak BMD in the polynomial regression model was achieved at 26 years in males and 36 years in females in the total hip, at 20 years in males and 27 years in females in the femoral neck, and at 20 years in males and 30 years in females in the lumbar spine. The prevalence of osteoporosis over the age of 50 years showed significant variation of up to two fold depending on the reference standards adopted. The age at which peak BMD was achieved was variable according to the gender and body sites. A consistent definition of peak BMD needs to be established in terms of age ranges because this could affect the prevalence of osteoporosis and healthcare policies.

Prevalence of and risk factors for osteoporosis in adults with acquired brain injury

BACKGROUND

Low bone mineral density (BMD) is common in older people with stroke, particularly in the paretic limb. Younger people with acquired brain injury (ABI), of all causes, are at increased risk of low BMD.

AIMS

To examine prevalence of low BMD, based on World Health Organisation diagnostic criteria, in patients with ABI.

METHODS

This is a cross-sectional study of 112 ABI patients. All completed a questionnaire, had laboratory investigations and DXA assessment of lumbar spine and one or both hips.

RESULTS

Mean age ± SD of participants was 45.7 ± 13.7 years. Risk of vitamin D deficiency (25-OHD < 30 nmol/L) occurred in 27.7 %, 34.3 % had adequate levels (30-50 nmol/L) and 36.6 % had levels in excess of this. Based on T-scores, 41.1 % had osteopenia and 21.4 % had osteoporosis. A Z score of -1 or less but greater than -2 occurred in 25 %; a further 21.4 % had a Z score of -2 or less. Patients who could walk outdoors had significantly higher BMD at the neck of femur than those who walked indoors only and those who could not walk at all (p < 0.001). On multiple linear regression analysis, ambulatory ability and duration of disability were independent predictors of BMD at sound neck of femur and total proximal femur.

CONCLUSIONS

Osteopenia and osteoporosis are common in young adults with ABI compared with the general population. Bone heath monitoring should form part of the long-term follow-up of this patient group.

Cross-sectional and prospective associations between dietary and plasma vitamin C, heel bone ultrasound, and fracture risk in men and women in the European Prospective Investigation into Cancer in Norfolk cohort

BACKGROUND

Vitamin C sufficiency may help prevent osteoporosis and fractures by mediating osteoclastogenesis, osteoblastogenesis, and bone collagen synthesis.

OBJECTIVE

We determined whether dietary intakes and plasma concentrations of vitamin C were associated with a heel ultrasound and hip and spine fracture risks in older men and women.

DESIGN

Participants were recruited from the European Prospective Investigation into Cancer in Norfolk study with 7-d diet diary estimates of vitamin C intake and plasma concentrations. A random subset (4000 of 25,639 subjects) was available for the cross-sectional (ultrasound) study of broadband ultrasound attenuation (BUA) and velocity of sound (VOS), which were determined during the second health examination. The prospective (fracture) study was a case-cohort sample of all participants with a fracture up to March 2009 and the random subset (n = 5319). ANCOVA-determined associations between quintiles of vitamin C intake and plasma status with adjusted BUA and VOS and adjusted Prentice-weighted Cox proportional HRs were calculated for fracture risk.

RESULTS

Women were 58% of the population (39-79 y old), and the median follow-up was 12.6 y (range: 0-16 y). Positive associations across all quintiles of vitamin C intake but not plasma status were significant for VOS in men (β = 2.47 m/s, P = 0.008) and BUA in women (β = 0.82 dB/MHz, P = 0.004). Vitamin C intake was not associated with fracture risk, but there was an inverse association with plasma concentrations in men, with quintile 4 having significantly lower risks of hip fractures (HR: 0.35; 95% CI: 0.16, 0.80) and spine fractures (HR: 0.26; 95% CI: 0.10, 0.69) than quintile 1.

CONCLUSIONS

Higher vitamin C intake was significantly associated with higher heel ultrasound measures in men and women, and higher plasma vitamin C concentrations were significantly associated with reduced fracture risk in men only. Our findings that vitamin C intake and status were inconsistently associated with bone health variables suggest that additional research is warranted.

Prediction of incident hip fracture with the estimated femoral strength by finite element analysis of DXA Scans in the study of osteoporotic fractures

A bone fractures only when loaded beyond its strength. The purpose of this study was to determine the association of femoral strength, as estimated by finite element (FE) analysis of dual-energy X-ray absorptiometry (DXA) scans, with incident hip fracture in comparison to hip bone mineral density (BMD), Fracture Risk Assessment Tool (FRAX), and hip structure analysis (HSA) variables. This prospective case-cohort study included a random sample of 1941 women and 668 incident hip fracture cases (295 in the random sample) during a mean ± SD follow-up of 12.8 ± 5.7 years from the Study of Osteoporotic Fractures (n = 7860 community-dwelling women ≥67 years of age). We analyzed the baseline DXA scans (Hologic 1000) of the hip using a validated plane-stress, linear-elastic finite element (FE) model of the proximal femur and estimated the femoral strength during a simulated sideways fall. Cox regression accounting for the case-cohort design assessed the association of estimated femoral strength with hip fracture. The age-body mass index (BMI)-adjusted hazard ratio (HR) per SD decrease for estimated strength (2.21; 95% CI, 1.95-2.50) was greater than that for total hip (TH) BMD (1.86; 95% CI, 1.67-2.08; p < 0.05), FN BMD (2.04; 95% CI, 1.79-2.32; p > 0.05), FRAX scores (range, 1.32-1.68; p < 0.0005), and many HSA variables (range, 1.13-2.43; p < 0.005), and the association was still significant (p < 0.05) after further adjustment for hip BMD or FRAX scores. The association of estimated strength with incident hip fracture was strong (Harrell's C index 0.770), significantly better than TH BMD (0.759; p < 0.05) and FRAX scores (0.711-0.743; p < 0.0001), but not FN BMD (0.762; p > 0.05). Similar findings were obtained for intracapsular and extracapsular fractures. In conclusion, the estimated femoral strength from FE analysis of DXA scans is an independent predictor and performs at least as well as FN BMD in predicting incident hip fracture in postmenopausal women.

Early development and osteoporosis and bone health

Osteoporosis is a skeletal disorder characterized by low bone mass and micro-architectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture. Evidence is now accumulating from human studies that programming of bone growth might be an important contributor to the later risk of osteoporotic fracture. Body weight in infancy is a determinant of adult bone mineral content, as well as of the basal levels of activity of the growth hormone/insulin-like growth factor-1 (GH/IGF-1) and hypothalamo-pituitary-adrenal (HPA) axes, and recent work has suggested a central role for vitamin D. Epidemiological studies have shown that maternal smoking and nutrition during pregnancy influence intrauterine skeletal mineralization. Childhood growth rates have been directly linked to the risk of hip fracture many decades later, and now evidence is emerging from experimental animal studies that support these observational data. Recent studies have also highlighted epigenetic phenomena as potential mechanisms underlying the findings from epidemiological studies.

Programming of osteoporosis and impact on osteoporosis risk

Osteoporosis is a skeletal disorder characterized by reduced bone quantity and quality and an increased susceptibility to fracture, and seems to be one of many chronic conditions that might be influenced by events early in life. Specifically, there is growing evidence of an interaction between the genome and the environment in the expression of the disease.

Use of DXA-based finite element analysis of the proximal femur in a longitudinal study of hip fracture

Bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) is used for clinical assessment of fracture risk; however, measurements that incorporate bone strength could improve predictive ability. The aim of this study was to determine whether bone strength derived from finite element (FE) analysis was associated with hip fracture risk in a longitudinal study. We studied 728 women (mean age 82 years), 182 with subsequent hip fracture. FE models were generated from baseline DXA scans of the hip to determine femoral bone strength and load-to-strength ratio (LSR). The baseline LSR was significantly higher in fracture cases (median 1.1) compared with controls (0.7, p < 0.0001). Femoral strength and BMD were also significantly lower in cases (median 1820 N, 0.557 g/cm(2)) compared with controls (2614 N, 0.618 g/cm(2) ) both p < 0.0001. Fracture risk increased per standard deviation decrease in femoral strength (odds ratio [OR] = 2.2, 95% confidence interval [CI] 1.8-2.8); femoral neck (FN) BMD (OR = 2.1, 95% CI 1.7-2.6); total hip BMD (OR = 1.8, 95% CI 1.5-2.1); and per SD increase in LSR (OR = 1.8, 95% CI 1.5-2.1). After adjusting for FN BMD, the odds ratio for femoral strength (OR = 1.7, 95% CI 1.2-2.4) and LSR (OR = 1.4, 95% CI 1.1-1.7) remained significantly greater than 1. The area under the curve (AUC) for LSR combined with FN BMD (AUC 0.69, 95% CI 0.64-0.73) was significantly greater than FN BMD alone (AUC 0.66, 95% CI 0.62-0.71, p = 0.004). Strength and LSR remained significant when adjusted for prevalent fragility fracture, VFA, and FRAX score. In conclusion, the DXA-based FE model was able to discriminate incident hip fracture cases from controls in this longitudinal study independently from FN BMD, prior fracture, VFA, and FRAX score. Such an approach may provide a useful tool for better assessment of bone strength to identify patients at high risk of hip fracture who may benefit from treatment to reduce fracture risk.

Osteogenesis response to implanted materials in endocortical bone in rat femora

BACKGROUND

Orthopedic surgeons and dentists often implant materials to repair bone tissue defects and restore physiological functions of bone organs. The clinical success depends on adequate bone formation in operation sites. However, the real cause of osteogenesis has not yet been fully elucidated. To investigate the bone response to implanted materials, this study examined the bone tissue reaction in rat femoral medullary canal, which received gelatin and collagen as foreign-body materials.

METHODS

A total of 36 six-month-old Sprague-Dawley rats were randomly and meanly divided into three groups. In the gelatin group, the bilateral femora received gelatin material; in the collagen group, they were implanted with type I collagen, and in the control group, the femora suffered from sham operation with no materials inserted. After 2, 4, 8, and 12 weeks, specimens were harvested and subjected to a series of examinations.

RESULTS

After 2 weeks of healing, a significant upregulation of both alkaline phosphatase and osteocalcin by both kinds of implanted materials relative to the control (sham implantation group) was seen in gene expression analysis. Strong reactivity of osteoprotegerin and receptor activator of NFκB ligand was detected in the two test groups in immunohistochemistry at 4 weeks of healing. Also, micro-CT revealed an increase in cortical bone thickness in the two test groups as compared to the control group. Densitometry showed increased bone mineral density in the bone receiving materials after 12 weeks, leading to the enhanced maximum load in the test groups.

CONCLUSIONS

These results indicated that the implanted materials led to an osteogenesis response in rat femoral medullary canal. Thus, we probably should reconsider the potential cascades of tissue reaction when utilizing orthopedic and dental implants and other materials to recover bone related-organ function and repair bone defects.

Genetic influence on bone mineral density in Korean twins and families: the healthy twin study

Bone mineral density (BMD), a representative marker of osteoporosis risk, is found to be highly heritable in this Korean study, which is very consistent with the findings in Western populations. This finding strongly supports that genetic factors are significant determinants of osteoporosis risk along with individual biological and behavioral factors.

INTRODUCTION

Although genetic factors are known to contribute significantly to variations in BMD in Western populations, such an association has not been fully evaluated in an Asian population. This study was conducted to determine the role of genetic factors on BMD in Korean population.

METHODS

The study participants were 2,728 men and women consisting of 497 monozygotic (MZ) twin pairs, 119 dizygotic (DZ) twin pairs, and 1,496 first-degree relatives from the Healthy Twin Study. BMD was measured using dual-energy X-ray absorptiometry. Quantitative genetic analysis based on a variance decomposition model was performed.

RESULTS

Age and the measured covariates accounted for 17~61% of the variation in BMD, depending on the sites of measurement. After accounting for the covariate effects, the heritability of BMD at the whole body, thoracic and lumbar spine, whole ribs, whole pelvis, whole arms, and whole legs were 0.76, 0.72, 0.73, 0.71, 0.51, and 0.75, respectively. The pair-wise correlation of BMD was the highest within MZ twin pairs, followed by DZ twin pairs, sibling pairs, and parents-child pairs. Cross-trait correlation analysis revealed a positive genetic correlation between BMDs at different sites, ranging from 0.80 (arm and leg BMD) to 0.50 (pelvis and arm BMD).

CONCLUSIONS

The high heritability of BMD in this Korean population similar to those found in Western populations and the significant common genetic basis between BMDs at different sites strongly supports a significant role of genetic determinants on the risk of osteoporosis.

Is antipsychotic treatment linked to low bone mineral density and osteoporosis? A review of the evidence and the clinical implications

OBJECTIVE

Osteoporosis is increasingly common worldwide and there is a growing concern that the long-term use of antipsychotic medications increases the risk of this disorder. In this review, we consider whether antipsychotics may contribute to the development of osteoporosis through reductions in bone mineral density, discuss the possible mechanisms involved and consider the clinical implications of such a relationship.

METHODS

We searched the literature for studies in this area published between 1966 and 2010 using the Medline and PubMed databases, supplemented by hand searches of retrieved reports.

RESULTS

The available data indicate that statistically significant reductions in bone mineral density are frequently seen in patients prescribed with antipsychotic medications and suggest that there is a higher incidence of clinically significant reductions compared with the normal population.

CONCLUSIONS

Clinicians should be aware for the potential negative effects of antipsychotic medications on bone mineral density, particularly in patients with additional risk factors for osteoporosis. Recommendations regarding routine monitoring of bone mineral density for patients prescribed antipsychotic medications cannot be made on the basis of existing evidence, and more research is required.

The pathogenesis, diagnosis, investigation and management of osteoporosis

With an increasingly ageing population, osteoporosis and osteoporosis-related fractures is fast becoming an important public health problem placing a considerable economic burden on health service resources. This does not account for the substantial pain, disability and indeed mortality incurred after a fracture, particularly a hip fracture. Osteoporosis is a systemic skeletal disorder which results from an imbalance in bone remodeling. This leads to a reduction in bone strength and increased susceptibility to fracture. It affects up to 1 in 2 women and 1 in 5 men. In the past 2 decades, there have been significant advances in bone biology which have helped in the understanding of the pathogenesis of osteoporosis and have led to improved therapies. In developing strategies for fracture prevention, it is important to identify those individuals with the highest fracture risk who will require pharmacological intervention. Treatment is aimed at fracture prevention and includes modification of general lifestyle factors which have been linked to fractures in epidemiological studies and ensuring optimum calcium and vitamin D intake as adjunct to active anti-fracture therapy. A number of drugs are now approved for the treatment of osteoporosis. This review article will describe the pathogenesis of osteoporosis and focus on the methods currently in use for the identification of patients at high fracture risk and will highlight their usefulness and limitations. The existing anti-fracture pharmacotherapies and those in development will be reviewed. Assessment of their effectiveness including the use of biochemical markers of bone turnover in this clinical context will be reviewed.

Similarities in acquired factors related to postmenopausal osteoporosis and sarcopenia

Postmenopausal population is at increased risk of musculoskeletal impairments. Sarcopenia and osteoporosis are associated with significant morbidity and social and health-care costs. These two conditions are uniquely linked with similarities in pathophysiology and diagnostic methods. Uniform diagnostic criteria for sarcopenia are still evolving. Postmenopausal sarcopenia and osteoporosis share many environmental risk- and preventive factors. Moreover, geriatric frailty syndrome may result from interaction of osteoporosis and sarcopenia and may lead to increased mortality. The present paper reviews the factors in evolution of postmenopausal sarcopenia and osteoporosis.

Steroidal contraceptives: effect on bone fractures in women

BACKGROUND

Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. Osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally.

OBJECTIVES

To evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women

SEARCH STRATEGY

We searched for studies of fracture or bone health and hormonal contraceptives in MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS, as well as ClinicalTrials.gov and ICTRP. We wrote to investigators to find additional trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) were considered if they examined fractures, bone mineral density (BMD), or bone turnover in women with hormonal contraceptive use prior to menopause. Interventions could include comparing a hormonal contraceptive with a placebo or another hormonal contraceptive or could compare providing a supplement versus a placebo.

DATA COLLECTION AND ANALYSIS

We assessed all titles and abstracts identified through the literature searches. Mean differences were computed using the inverse variance approach. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) was calculated. Both included the 95% confidence interval (CI) and used a fixed-effect model. Due to different interventions, no trials could be combined for meta-analysis.

MAIN RESULTS

Of the 16 RCTs we found, 2 used a placebo and 1 used a non-hormonal method as the comparison, while 13 compared two hormonal contraceptives. No trial had fracture as an outcome. Most measured BMD and several assessed bone turnover. Depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density. The placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo. Combination contraceptives did not appear to negatively affect bone health, but none were placebo-controlled. For implants, the single-rod etonogestrel group showed a greater BMD decrease versus the two-rod levonorgestrel group. However, results were not consistent across all implant comparisons.

AUTHORS' CONCLUSIONS

Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Many trials had small numbers of participants and some had large losses to follow up. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.

Osteoporotic fractures in the Brazilian community-dwelling elderly: prevalence and risk factors

The risk of osteoporotic fractures is known to vary among populations. There are no studies analyzing concomitantly clinical, densitometric, and lab risk factors in miscigenated community-dwelling population of Brazil. A total of 1007 elderly subjects (600 women and 407 men) from São Paulo, were evaluated using a questionnaire that included risk factors for osteoporotic fractures. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the hip and lumbar spine. Laboratory blood tests were also obtained. The prevalence of osteoporotic fractures was 13.2% (133 subjects), and the main fracture sites were distal forearm (6.0%), humerus (2.3%), femur (1.3%), and ribs (1.1%). Women had a higher prevalence (17.5%; 95% confidence interval [CI]: 14.6-20.6) than men (6.9%; 95% CI: 4.4-9.3) (p<0.001). After adjusting for significant variables, logistic regression revealed that female gender (odds ratio [OR]=2.7; 95% CI; 1.6-4.5; p<0.001), current smoking (OR=1.9; 95% CI: 1.2-3.3; p=0.013), and the femoral neck T-score (OR=0.7; 95% CI: 0.5-0.9; p=0.001) remain significant risk factors for osteoporotic fractures in the community-dwelling elderly. Our findings identified that female gender, current smoking, and low hip BMD are independent risk factors for osteoporotic fractures.

Bone health-related factors and the use of bisphosphonates in community setting--15-year follow-up study

The present study investigated the bone health related factors that were associated with the use of bisphosphonates (BP) among 2,050 postmenopausal Finnish women. Low BMD + low trauma energy fracture was the strongest determinant of BP use, while other secondary causes of osteoporosis were less strongly related with BP use. BP use was associated with reduced femoral neck (FN) and lumbar spine (LS) bone loss rate.

INTRODUCTION

The aim was to identify bone health related factors associated with the use of BP in a community setting.

METHODS

A population-based sample of 2,050 Finnish postmenopausal women was measured with dual X-ray absorptiometry at the FN and LS in 1989, 1994, 1999 and 2004, and information on osteoporosis risk factors, including low-trauma energy fractures, were collected with postal inquiries. Self-reported use of BP in 2004 was considered as the end point variable.

RESULTS

Among BP users, 12% had T-score > -2.0 SD and no fracture during follow-up (FU). In women without any bone medication, 26% had T-score < -2.0 SD or low-trauma energy fracture or both during the FU. In BP users, a significant reduction in FN and LS bone loss rate, cumulative with duration of use, was observed in ANCOVA (p < 0.001). Among BP users, there was a significantly higher proportion of women with several independent risk factors for osteoporosis and more spine and humerus fractures but less ankle fractures. T-score < -2 SD combined with low-trauma energy fracture was significantly related to the use of BPs (p < 0.001, OR = 15.96) and T-score < -2 SD was a stronger predictor of BP use (p < 0.001, OR = 13.29) than fracture (p > 0.05, OR = 1.35) in multivariate logistic regression. Other factors related with BP use were vitamin D use (p = 0.001, OR = 2.27), high number of medications (p < 0.001, OR = 1.26) and rheumatoid arthritis (p < 0.05, OR 2.55).

CONCLUSIONS

These findings reveal the recent bone health-related indications for BP prescription.

The role of the nurse in the management of osteoporosis

Osteoporosis is a chronic disease which is asymptomatic until fractures occur. It is an increasing problem within an ageing population and has many intrinsic and extrinsic risk factors. This article provides an overview of osteoporosis,including the pathogenesis, diagnosis and management.Multidisciplinary assessment and management of osteoporosis is essential with the apt use of non-pharmacologic and pharmacological options to minimize the risk of fracture and appropriately manage patients in an holistic manner.

Healthy midlife Canadian women: how bone health is considered in their food choice systems

BACKGROUND

The incidence of osteoporosis is predicted to increase as Western populations age. Diet is considered to be an important modifiable factor in bone health, yet the diets of many women are insufficient in calcium and vitamin D, which comprise two key nutrients for bone health. This focus group study explored ways in which midlife women consider bone health in their personal food choice systems.

METHODS

Data were obtained in six audio-recorded focus groups from a total of 36 women from upper, middle and lower income neighbourhoods. Open and axial coding and thematic analysis revealed shared and unique themes across and within the income groups. Use of member checks, peer debriefing, and independent and team data analysis enhanced rigour in the findings.

RESULTS

All participants were aware of osteoporosis. Most women idealised making simple food decisions and eating for 'holistic' health, but not specifically for bone health. Most midlife women were not motivated to change their diets, few had deliberately increased their intake of calcium and vitamin D through foods and supplements, and few others had simplified their food decisions.

CONCLUSIONS

Midlife women in the present study did not make eating for bone health a priority in their food choice systems. Instead, women wanted to eat for 'holistic' health, and only by implication bone health.

Pharmacologic undertreatment of osteoporosis in Austrian nursing homes and senior's residences

Osteoporosis is a classical age-related disease. Although significant progress in treatment has been achieved and antifracture efficacy proven over the past years undertreatment is still a general problem. There are only few published data available regarding osteoporosis and its treatment encountered in Austrian nursing homes and seniors' residences where fractures are especially frequent. We therefore conducted a survey in 89 participating institutions in order to assess frequency of documented osteoporosis as well as prevalence status of anti-osteoporotic drug usage in this special population. Data were acquired using a questionnaire and analyzed in a descriptive manner. Mean age of the residents was 82 years and the majority was female (76%). Half of the subjects took 5-8 different drugs per day and 23% received more than 8. Almost one-fourth (21.2%) of the residents had a diagnosis of osteoporosis. A history of hip fracture or other fractures was documented in 10.4% and 13.2%, respectively. Only 8.2% of the residents were treated with calcium, 6.2% with vitamin D and 9.3% received a combination of vitamin D and calcium. Specific osteoporosis treatment was prescribed to 7.2% only. In conclusion, this study reflects a high degree of continuing unawareness toward a diagnosis of osteoporosis in Austrian nursing homes and seniors' residences. The data of this survey further indicate that undertreatment is still very common in this population at very high risk of fractures.

Effect of the supplementation of dietary rich phytoestrogens in altering the vitamin D levels in diet induced osteoporotic rat model

Plant-derived estrogen-like compounds such as isoflavones (IF) especially daidzein and genistein are said to be preserving the bone in the osteoporotic conditions. However, it is not known whether a combination of IF and calcium (Ca) supplementation attenuates losses in bone mass and prevents the loss of vitamin D (VD). The present study addresses the role of phytoestrogens (PE) and Ca supplementation in low Ca and low VD diet induced osteoporosis (OSP). Cowpea (CP) which has high amount of the IF was selected to study its effect on diet induced osteoporotic conditions. Female weanling WNIN rats (total of 68) were divided into five groups and fed for five weeks on semisynthetic diet with low Ca (0.15%) and low VD (0.1IU/day/rat) in combination with low (10 mg/kg) or high (25 mg/kg) concentrations of PEs derived from CPIF. The study groups are: (I) normal Ca(0.47%) and normal VD (25IU/day/rat), (II) low Ca+low VD, (III) low Ca+low VD+low CPIF (10 mg/kg diet), (IV) low Ca+low VD+high CPIF (25 mg/kg diet) and (V) low Ca+low VD+17-(-estradiol (3.2 mg/kg diet). After the development of OSP the group II was subgrouped into: (SG I) continued on low Ca+VD, (SG II) low CPIF, (SG III) high CPIF, (SG IV) 17-beta-estradiol and (SG V) normal Ca and VD. Serum 25-VD levels were in the range of 14-38 ng/ml in groups I, III, IV and V, where as the values were very low in the group II (5.8 ng/ml). These were partially reversed upon supplementation of CPIF. The results correlated with altered Ca levels, body weight, bone mineral density and content and other related biochemical parameters. The paper further explains the possibility of protective and therapeutic role of VD in the presence of CPIF in osteoporotic health manifestations.

Erythrina variegata extract exerts osteoprotective effects by suppression of the process of bone resorption

Our previous study showed that Erythrina variegata L. (EV) inhibited bone loss and improved bone properties in ovariectomised rats. The purpose of the present study is to investigate the potential mechanism involved in mediating the osteoprotective actions of EV. Female Sprague–Dawley rats were fed a phyto-oestrogen-free diet and subjected to either ovariectomy or a sham operation. Ovariectomised rats were treated with genistein (40 mg/kg) as well as low (200 mg/kg), medium (500 mg/kg) or high (1000 mg/kg) doses of EV extract. Bone properties and mRNA expressions were evaluated by micro-computed tomography and quantitative RT-PCR, respectively. Osteoclast differentiation in RAW 264·7 cells was studied by tartrate-resistant acid phosphatase (TRAP) staining. High doses of EV could decrease urinary Ca and P excretion, maintain serum Ca and P level, and exert beneficial effects on the micro-structure and morphology of trabecular bone and cortical bone in ovariectomised rats. EV suppressed the up-regulation of cathepsin K mRNA and the down-regulation of osteoprotegrin mRNA in the tibia of ovariectomised rats. TRAP-positive cell numbers were significantly decreased in receptor activator of nuclear factor-κB ligand (RANKL)-induced RAW 264·7 cells when co-cultured with EV extracts. The present study indicated that the protective effects of EV on bone properties in ovariectomised rats are likely to be mediated by its inhibitory actions on the process of bone resorption via the suppression of osteoclast differentiation and maturation.

Bone Loss Rate May Interact with Other Risk Factors for Fractures among Elderly Women: A 15-Year Population-Based Study

Aim was to investigate fracture risk (FR) according to bone loss (BL) rate. A random sample of 1652 women aged 53.5 years was measured with dual X-ray absorptiometry in femoral neck in 1989 and 1994 and divided into tertiles of annual BL rate: high >0.84%, moderate 0.13%-0.84%, and low <0.13%. Low trauma energy fractures during following 10 years were recorded. There were no differences in FR between BL tertiles in Cox regression model. Factors predicting lower FR in Cox model were in high tertile: high T-score (HR 0.71; 95% CI 0.54-0.93, P = .012), no sister's fracture (HR 0.35; 0.19-0.64, P = .001), no mother's fracture (HR 0.52; 0.31-0.88, P = .015), in moderate tertile: high T-score (HR 0.69;0.53-0.91, P = .008) and good grip strength (HR 0.98; 0.97-0.99, P = .022). In low tertile there were no predictors for FR. BL predicted FR in women with mother's fracture in univariate and multivariate model (OR 2.6; 1.15-5.7, P = .021) but with sister's fracture this was observed only in multivariate model (OR 2.66; 1.09-6.7, P = .039). Accordingly, the risk factors for postmenopausal fractures, especially mother's fracture, may interact with BL.

Variation in bone mineral density by anatomical site in patients with proximal humeral fractures

Low-energy fractures of the proximal humerus indicate osteoporosis and it is important to direct treatment to this group of patients who are at high risk of further fracture. Data were prospectively collected from 79 patients (11 men, 68 women) with a mean age of 69 years (55 to 86) with fractures of the proximal humerus in order to determine if current guidelines on the measurement of the bone mineral density at the hip and lumbar spine were adequate to stratify the risk and to guide the treatment of osteoporosis. Bone mineral density measurements were made by dual-energy x-ray absorptiometry at the proximal femur, lumbar spine (L2-4) and contralateral distal radius, and the T-scores were generated for comparison. Data were also collected on the use of steroids, smoking, the use of alcohol, hand dominance and comorbidity.

The mean T-score for the distal radius was −2.97 (sd 1.56) compared with −1.61 (sd 1.62) for the lumbar spine and −1.78 (sd 1.33) for the femur. There was a significant difference between the mean lumbar and radial T scores (1.36 (1.03 to 1.68); p < 0.001) and between the mean femoral and radial T-scores (1.18 (0.92 to 1.44); p < 0.001). The inclusion of all three sites in the determination of the T-score increased the sensitivity to 66% compared with that of 46% when only the proximal femur and lumbar spine were used. This difference between measurements in the upper limb compared with the axial skeleton and lower limb suggests that basing risk assessment and treatment on only the bone mineral density taken at the hip or lumbar spine may misrepresent the extent of osteoporosis in the upper limb and the subsequent risk of fracture at this site.

The assessment of osteoporosis must include measurement of the bone mineral density at the distal radius to avoid underestimation of osteoporosis in the upper limb.

Steroidal contraceptives: effect on bone fractures in women

BACKGROUND

Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. However, osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally.

OBJECTIVES

To evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women

SEARCH STRATEGY

We searched for studies of fracture or bone health and hormonal contraceptives in MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS, as well as in clinical trials databases (ClinicalTrials.gov and ICTRP). We wrote to investigators to find additional trials.

SELECTION CRITERIA

Randomized controlled trials were considered if they examined fractures, bone mineral density (BMD), or bone turnover in women with hormonal contraceptive use prior to menopause. Studies were excluded if hormones were provided for treatment of a specific condition rather than for contraception. Interventions could include comparisons of a hormonal contraceptive with a placebo or with another hormonal contraceptive. Interventions could also include the provision of a supplement versus a placebo.

DATA COLLECTION AND ANALYSIS

We assessed for inclusion all titles and abstracts identified through the literature searches with no language limitation. The mean difference was computed with 95% confidence interval (CI) using a fixed-effect model.

MAIN RESULTS

We found 13 RCTs, 2 of which used a placebo. No trial had fracture as an outcome but most measured BMD. Combination contraceptives did not appear to affect bone health. Of progestin-only methods, depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density, while results were inconsistent for implants. The two placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo.

AUTHORS' CONCLUSIONS

Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Due to different interventions, no trials could be combined for meta-analysis. Many trials had small numbers of participants and some had large losses to follow up. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.

Sister's fracture history may be associated with perimenopausal bone fragility and modifies the predictability of fracture risk

SUMMARY

The present study investigated the effects of first degree relatives' fractures on fracture incidence after the menopause. Sister's, but not other relatives', wrist or hip fracture history was associated with increased risk of fragility fractures after the menopause. This suggests genetic predisposition to bone fragility among postmenopausal women.

OBJECTIVE

The aim of the present study was to investigate the association between first degree relatives' fractures and perimenopausal bone fragility.

MATERIALS AND METHODS

The study sample of 971 perimenopausal women was extracted from randomly selected Kuopio Osteoporosis Risk Factor and Prevention cohort and measured with dual X-ray absorptiometry in femoral neck (FN) in baseline (1989-1991), in 5 years (1994-97), and in 10 years (1999-2001). All low-trauma energy fractures during the 10-year follow-up were recorded based on self-reports and validated from medical records. First degree relatives' history of life-time hip and wrist fractures (exact classification or trauma energy not specified) was questioned by postal inquiries.

RESULTS

There was a significant correlation between fathers' vs. brothers' and mothers' vs. sisters' fractures (p < 0.01 in Pearson bivariate correlations). Sister's, but not mother's, father's, or brother's wrist and hip fractures were associated with significantly lowered 10-year fragility fracture-free survival rate (HR = 0.56, p = 0.006). Sisters' or other relatives' fractures were not associated with FN bone loss rate or bone mineral density (BMD) in the follow-up measurements (p = NS in ANCOVA). The predictive power of BMD for fragility fractures differed according to sisters' fracture history: Baseline FN T score predicted fracture-free survival only among women without sisters' fracture history (HR 0.62, p < 0.001 vs. women with sisters' fracture in Cox regression).

CONCLUSIONS

In conclusion, sisters' fracture history is associated with 10-year fracture-free survival in perimenopausal women but not with BMD or its changes. Predictability of fragility fracture risk with BMD may depend on sister's fracture history. This may indirectly suggest genetic predisposition to bone fragility independently of BMD.

Bone mineral density at the hip in Norwegian women and men--prevalence of osteoporosis depends on chosen references: the Tromsø Study

This study describes bone mineral density (BMD) and the prevalence of osteoporosis in women and men between 30-89 years in an unselected population. BMD was measured in g/cm(2) at total hip and femoral neck by dual-energy-X-ray absorptiometry in 3,094 women and 2,132 men in the 2001 Tromsø Study. BMD levels were significantly explained by age and declined progressively in both sexes from middle into old age, with highest decline in women. With osteoporosis defined as a T-score of two and a half standard deviation below the young adult mean BMD, the prevalence at the total hip in subjects above 70 years was 6.9% in men and 15.3% in women, respectively, using the Lunar reference material for T-score calculations. The prevalence increased significantly to 7.3% in men and 19.5% in women, when T-scores were calculated on basis of the young adult mean BMD (age group 30-39 years) in the study population. At the femoral neck, prevalence of osteoporosis increased from 13.5 to 18.5% in men, and from 20.4 to 35.2% in women above 70 years, respectively, depending on how T-scores were calculated. The study highlights the challenges with fixed diagnostic levels when measuring normally distributed physiologic parameters. Although BMD only partly explains fracture risk, future studies should evaluate which calculations give optimal fracture prediction.

Management of osteoporosis with PTH: treatment and prescription patterns in Europe

BACKGROUND

PTH is an anabolic agent that promotes new bone formation and offers additional therapeutic options for the treatment of postmenopausal osteoporosis. Two forms of PTH are licensed for treatment of postmenopausal osteoporosis and are available in most European countries. Both demonstrate safety and efficacy in clinical trials with similar increases in bone mineral density (BMD) at the spine, total hip and femoral neck, and reductions in the number of vertebral fractures in postmenopausal women. The effect on the number of patients treated with PTH is analysed in terms of the total number of osteoporotic patients and total number of eligible patients, as defined by a literature review of vertebral fracture incidence in European populations.

AIMS

To analyse the management and treatment of postmenopausal osteoporosis with PTH in terms of the prescription patterns for PTH in five European countries and the underlying reasons for observed rates of prescription in each country.

FINDINGS

Osteoporosis patients with low vertebral BMD and two fractures are at appreciable risk of sustaining further fractures, particularly hip fractures. Hip fractures are associated with significant mortality and huge economic cost to society. These patients are approved for treatment with PTH but the availability of this therapy varies considerably across Europe. The number of patients receiving PTH varies from 0.24% of eligible patients in the UK to approximately 5% of eligible patients in Spain.

CONCLUSION

Large differences (up to 20-fold) exist in the number of patients receiving PTH across the five European countries. The reasons for the different accessibility to PTH arise from a combination of restrictive schedules of reimbursement, high cost and lack of knowledge of the potential benefits of PTH by physicians.

Genetic influences on bone loss in the San Antonio Family Osteoporosis study

The genetic contribution to age-related bone loss is not well understood. We estimated that genes accounted for 25-45% of variation in 5-year change in bone mineral density in men and women. An autosome-wide linkage scan yielded no significant evidence for chromosomal regions implicated in bone loss.

INTRODUCTION

The contribution of genetics to acquisition of peak bone mass is well documented, but little is known about the influence of genes on subsequent bone loss with age. We therefore measured 5-year change in bone mineral density (BMD) in 300 Mexican Americans (>45 years of age) from the San Antonio Family Osteoporosis Study to identify genetic factors influencing bone loss.

METHODS

Annualized change in BMD was calculated from measurements taken 5.5 years apart. Heritability (h(2)) of BMD change was estimated using variance components methods and autosome-wide linkage analysis was carried out using 460 microsatellite markers at a mean 7.6 cM interval density.

RESULTS

Rate of BMD change was heritable at the forearm (h(2) = 0.31, p = 0.021), hip (h(2) = 0.44, p = 0.017), spine (h(2) = 0.42, p = 0.005), but not whole body (h(2) = 0.18, p = 0.123). Covariates associated with rapid bone loss (advanced age, baseline BMD, female sex, low baseline weight, postmenopausal status, and interim weight loss) accounted for 10% to 28% of trait variation. No significant evidence of linkage was observed at any skeletal site.

CONCLUSIONS

This is one of the first studies to report significant heritability of BMD change for weight-bearing and non-weight-bearing bones in an unselected population and the first linkage scan for change in BMD.

Sarcopenic obesity: definition, cause and consequences

PURPOSE OF REVIEW

Older obese persons with decreased muscle mass or strength are at special risk for adverse outcomes. We discuss potential pathways to muscle impairment in obese individuals and the consequences that joint obesity and muscle impairment may have on health and disability. Tantamount to this discussion is whether low muscle mass or, rather, muscle weakness should be used for the definition.

RECENT FINDINGS

Excess energy intake, physical inactivity, low-grade inflammation, insulin resistance and changes in hormonal milieu may lead to the development of so-called 'sarcopenic obesity'. It was originally believed that the culprit of age-related muscle weakness was a reduction in muscle mass, but it is now clear that changes in muscle composition and quality are predominant. We propose that the risk of adverse outcomes, such as functional limitation and mortality, is better estimated by considering jointly obesity and muscle strength rather than obesity and muscle mass and the term 'sarcopenic obesity' should be revisited.

SUMMARY

Recognition of obese patients who have associated muscle problems is an essential goal for clinicians. Further research is needed to identify new target for prevention and cure of this important geriatric syndrome.

Epidemiology and outcome after hip fracture in the under 65s-evidence from the Scottish Hip Fracture Audit

AIM

To report the epidemiology and outcomes after hip fractures in the patients under 65 years of age.

PATIENTS AND METHODS

We performed a prospective, multi-centre observational study using the Scottish Hip Fracture Audit Database. Case-mix, process and outcome data was collected by dedicated coordinators on site at the time of admission, at 120 days after the injury and on any re-operations within 12 months. The study cohort consisted of 1896 individuals aged 50-64 years. Patient variables and outcomes were compared to a control group of 15,461 individuals aged 75-89 years of age. The control group consisted of three modal 5-year age groups centred about a median age of 83 years, equal to the database value, excluding the effects of the extreme elderly who may act as confounders. Outcomes measures included 30- and 120-day mortality, length of hospital stay, place of residence and ambulatory status. A multivariate logistic regression model was used to compare outcome between groups while controlling for significant case-mix variables.

RESULTS

Patients in the study cohort presented with lower ASA scores and were more likely to be independently mobile and live in their own home at the time of fracture (p<0.001). Pathological fractures were more common in younger patients and accounted for more than 1 in 20 fractures. Mortality at 30 and 120 days was significantly lower (p<0.0001) in the study cohort, however it was increased compared to age and gender adjusted mortality rates for the general population (p<0.001) Younger patients were more likely to recover independent mobility and living.

CONCLUSION

Patients aged 50-64 years have significantly better outcome measures after surgery for hip fracture in terms of survival and function. Such differences exist even after controlling for differences in patient case-mix variables.

Grip strength may facilitate fracture prediction in perimenopausal women with normal BMD: a 15-year population-based study

The aim of the present study was to investigate the ability of grip strength measurements to predict fracture risk in perimenopausal women according to bone mineral density (BMD). A random sample of 971 perimenopausal women from the Kuopio Osteoporosis Risk Factor and Prevention study cohort was measured with dual-energy X-ray absorptiometry (DXA) at the femoral neck and grip strength with a pneumatic squeeze dynamometer in 5-year intervals from baseline (1989-1991). Fractures during the 15-year follow-up were recorded based on self-reports and validated from medical records. In the total sample and in osteopenic or osteoporotic women (T score < -1, n = 284) grip strength was not significantly associated with fracture-free survival rate (P = nonsignificant in Cox regression). In women with normal baseline BMD (N-BMD, T score > -1, n = 687) the lowest grip strength quartile had a significantly lower fracture-free survival rate in the Cox proportional hazard model (P = 0.005, hazard ratio [HR] = 2.0). In the multivariate Cox regression model, T score and grip strength were the only significant predictors of 15-year fracture-free survival in the N-BMD group and a risk index (RI) was formed according to HRs of these two variables. High RI (0-5 points) was associated with significantly lower 15-year fracture-free survival rate (P = 0.001, HR = 0.137) in the N-BMD group. In contrast, 5-year T score was no better a predictor of fractures in the baseline N-BMD group (P = 0.04, HR = 0.36). In conclusion, grip strength predicts 15-year fracture-free survival in perimenopausal women with N-BMD, while 5-year DXA does not seem to be any better a predictor of fracture risk. DXA measurements could be coupled with simple and cost-effective grip strength measurements. Controlling BMD in women with N-BMD could be abandoned.

Natural history and risk factors for bone loss in postmenopausal Caucasian women: a 15-year follow-up population-based study

In this 15-year follow-up study, we found that the estimated rate of bone loss at the femoral neck (FN) for women aged 45-68 was linear at a rate of 1.67% per year, but quadratic for lumbar spine (LS) at a rate of 3.12% initially, and slowing down with age. We also confirmed the protective role of HRT, increasing weight, and lean mass in long-term bone loss.

INTRODUCTION

The objective was to describe the natural history of bone loss and explore the role of environmental factors in postmenopausal women over a 15-year period.

METHODS

Bone mineral density (BMD) at the FN and the LS were measured in postmenopausal women from the Chingford Study. Height, weight, HRT status, and calcium/vitamin D supplement were assessed at each visit. Osteoarthritis of hip and spine was assessed by X-ray at baseline and at year 8.

RESULTS

A total of 955 postmenopausal women with an average age of 54.7 at baseline were included. Both FN and LS BMD decreased significantly with age (p<0.0001). The decline was larger in the LS (-3.12% per year), which showed a quadratic relationship, than in the FN (-1.67% per year) with a linear relationship. The rate of bone loss was reduced by one third annually for the FN and LS respectively in current HRT users. Change in weight was positively associated with both DeltaFN and DeltaLS BMD (beta=0.16% and 0.09% change in DeltaFN and DeltaLS BMD per kilogramme change in weight respectively, p<0.0001 for both sites). Spine OA and progression were positively associated with DeltaLS BMD (beta=1.22% change in DeltaLS BMD per grade in spine OA and 0.45% change in DeltaLS BMD for patients who progressed, p<0.0001 for spine OA and p=0.002 for spine OA progression). Spine OA (beta=0.54% change in DeltaFN BMD per grade, p<0.0001), but not progression, and hip OA were positively associated with DeltaFN BMD. Furthermore, both age and body weight at baseline were positively associated with both DeltaFN and DeltaLS BMD (beta=0.02-0.04% change in DeltaFN and DeltaLS BMD per year increase in age at baseline and 0.004-0.007% change in DeltaFN and DeltaLS BMD per kilogramme increase in weight at baseline, all p<0.0001).

CONCLUSION

This large population-based longitudinal study demonstrated that the decline of BMD over 15 years is linear with age for the FN, but quadratic for the LS. The study confirmed the protective role of HRT, increased weight and lean mass in long-term bone loss.