Management of osteoporosis in postmenopausal women: 2006 position statement of The North American Menopause Society

Sirtuins: exploring next-gen therapeutics in the pathogenesis osteoporosis and associated diseases

OBJECTIVE

Osteoporosis poses a substantial public health challenge due to an ageing population and the lack of adequate treatment options. The condition is marked by a reduction in bone mineral density, resulting in an elevated risk of fractures. The reduction in bone density and strength, as well as musculoskeletal issues that come with aging, present a significant challenge for individuals impacted by these conditions, as well as the healthcare system worldwide.

METHODS

Literature survey was conducted until May 2023 using databases such as Web of Science, PubMed, Scopus, and Google Scholar.

RESULT

Sirtuins 1-7 (SIRT1-SIRT7), which are a group of Nicotinamide adenine dinucleotide (NAD+)-dependent deacetylases, possess remarkable capabilities to increase lifespan and combat diseases related to aging. Research has demonstrated that these proteins play an important role in regular skeletal development and maintenance by directly impacting bone cells. Their dysfunction could be a factor in various bone conditions. Studies conducted on animals before clinical trials have shown that administering Sirtuins agonists to mice provides a safeguard against osteoporosis resulting from aging, menopause, and immobilization. These findings imply that Sirtuins may be a viable target for addressing the irregularity in bone remodeling and treating osteoporosis and other skeletal ailments.

CONCLUSION

The purpose of this review was to present a thorough and current evaluation of the existing knowledge on Sirtuins biology, with a particular emphasis on their involvement in maintaining bone homeostasis and contributing to osteoporosis. Additionally, the review examines potential pharmacological interventions targeting Sirtuins for the treatment of osteoporosis.

Screening for the primary prevention of fragility fractures among adults aged 40 years and older in primary care: systematic reviews of the effects and acceptability of screening and treatment, and the accuracy of risk prediction tools

BACKGROUND

To inform recommendations by the Canadian Task Force on Preventive Health Care, we reviewed evidence on the benefits, harms, and acceptability of screening and treatment, and on the accuracy of risk prediction tools for the primary prevention of fragility fractures among adults aged 40 years and older in primary care.

METHODS

For screening effectiveness, accuracy of risk prediction tools, and treatment benefits, our search methods involved integrating studies published up to 2016 from an existing systematic review. Then, to locate more recent studies and any evidence relating to acceptability and treatment harms, we searched online databases (2016 to April 4, 2022 [screening] or to June 1, 2021 [predictive accuracy]; 1995 to June 1, 2021, for acceptability; 2016 to March 2, 2020, for treatment benefits; 2015 to June 24, 2020, for treatment harms), trial registries and gray literature, and hand-searched reviews, guidelines, and the included studies. Two reviewers selected studies, extracted results, and appraised risk of bias, with disagreements resolved by consensus or a third reviewer. The overview of reviews on treatment harms relied on one reviewer, with verification of data by another reviewer to correct errors and omissions. When appropriate, study results were pooled using random effects meta-analysis; otherwise, findings were described narratively. Evidence certainty was rated according to the GRADE approach.

RESULTS

We included 4 randomized controlled trials (RCTs) and 1 controlled clinical trial (CCT) for the benefits and harms of screening, 1 RCT for comparative benefits and harms of different screening strategies, 32 validation cohort studies for the calibration of risk prediction tools (26 of these reporting on the Fracture Risk Assessment Tool without [i.e., clinical FRAX], or with the inclusion of bone mineral density (BMD) results [i.e., FRAX + BMD]), 27 RCTs for the benefits of treatment, 10 systematic reviews for the harms of treatment, and 12 studies for the acceptability of screening or initiating treatment. In females aged 65 years and older who are willing to independently complete a mailed fracture risk questionnaire (referred to as "selected population"), 2-step screening using a risk assessment tool with or without measurement of BMD probably (moderate certainty) reduces the risk of hip fractures (3 RCTs and 1 CCT, n = 43,736, absolute risk reduction [ARD] = 6.2 fewer in 1000, 95% CI 9.0-2.8 fewer, number needed to screen [NNS] = 161) and clinical fragility fractures (3 RCTs, n = 42,009, ARD = 5.9 fewer in 1000, 95% CI 10.9-0.8 fewer, NNS = 169). It probably does not reduce all-cause mortality (2 RCTs and 1 CCT, n = 26,511, ARD = no difference in 1000, 95% CI 7.1 fewer to 5.3 more) and may (low certainty) not affect health-related quality of life. Benefits for fracture outcomes were not replicated in an offer-to-screen population where the rate of response to mailed screening questionnaires was low. For females aged 68-80 years, population screening may not reduce the risk of hip fractures (1 RCT, n = 34,229, ARD = 0.3 fewer in 1000, 95% CI 4.2 fewer to 3.9 more) or clinical fragility fractures (1 RCT, n = 34,229, ARD = 1.0 fewer in 1000, 95% CI 8.0 fewer to 6.0 more) over 5 years of follow-up. The evidence for serious adverse events among all patients and for all outcomes among males and younger females (<65 years) is very uncertain. We defined overdiagnosis as the identification of high risk in individuals who, if not screened, would never have known that they were at risk and would never have experienced a fragility fracture. This was not directly reported in any of the trials. Estimates using data available in the trials suggest that among "selected" females offered screening, 12% of those meeting age-specific treatment thresholds based on clinical FRAX 10-year hip fracture risk, and 19% of those meeting thresholds based on clinical FRAX 10-year major osteoporotic fracture risk, may be overdiagnosed as being at high risk of fracture. Of those identified as being at high clinical FRAX 10-year hip fracture risk and who were referred for BMD assessment, 24% may be overdiagnosed. One RCT (n = 9268) provided evidence comparing 1-step to 2-step screening among postmenopausal females, but the evidence from this trial was very uncertain. For the calibration of risk prediction tools, evidence from three Canadian studies (n = 67,611) without serious risk of bias concerns indicates that clinical FRAX-Canada may be well calibrated for the 10-year prediction of hip fractures (observed-to-expected fracture ratio [O:E] = 1.13, 95% CI 0.74-1.72, I² = 89.2%), and is probably well calibrated for the 10-year prediction of clinical fragility fractures (O:E = 1.10, 95% CI 1.01-1.20, I² = 50.4%), both leading to some underestimation of the observed risk. Data from these same studies (n = 61,156) showed that FRAX-Canada with BMD may perform poorly to estimate 10-year hip fracture risk (O:E = 1.31, 95% CI 0.91-2.13, I² = 92.7%), but is probably well calibrated for the 10-year prediction of clinical fragility fractures, with some underestimation of the observed risk (O:E 1.16, 95% CI 1.12-1.20, I² = 0%). The Canadian Association of Radiologists and Osteoporosis Canada Risk Assessment (CAROC) tool may be well calibrated to predict a category of risk for 10-year clinical fractures (low, moderate, or high risk; 1 study, n = 34,060). The evidence for most other tools was limited, or in the case of FRAX tools calibrated for countries other than Canada, very uncertain due to serious risk of bias concerns and large inconsistency in findings across studies. Postmenopausal females in a primary prevention population defined as <50% prevalence of prior fragility fracture (median 16.9%, range 0 to 48% when reported in the trials) and at risk of fragility fracture, treatment with bisphosphonates as a class (median 2 years, range 1-6 years) probably reduces the risk of clinical fragility fractures (19 RCTs, n = 22,482, ARD = 11.1 fewer in 1000, 95% CI 15.0-6.6 fewer, [number needed to treat for an additional beneficial outcome] NNT = 90), and may reduce the risk of hip fractures (14 RCTs, n = 21,038, ARD = 2.9 fewer in 1000, 95% CI 4.6-0.9 fewer, NNT = 345) and clinical vertebral fractures (11 RCTs, n = 8921, ARD = 10.0 fewer in 1000, 95% CI 14.0-3.9 fewer, NNT = 100); it may not reduce all-cause mortality. There is low certainty evidence of little-to-no reduction in hip fractures with any individual bisphosphonate, but all provided evidence of decreased risk of clinical fragility fractures (moderate certainty for alendronate [NNT=68] and zoledronic acid [NNT=50], low certainty for risedronate [NNT=128]) among postmenopausal females. Evidence for an impact on risk of clinical vertebral fractures is very uncertain for alendronate and risedronate; zoledronic acid may reduce the risk of this outcome (4 RCTs, n = 2367, ARD = 18.7 fewer in 1000, 95% CI 25.6-6.6 fewer, NNT = 54) for postmenopausal females. Denosumab probably reduces the risk of clinical fragility fractures (6 RCTs, n = 9473, ARD = 9.1 fewer in 1000, 95% CI 12.1-5.6 fewer, NNT = 110) and clinical vertebral fractures (4 RCTs, n = 8639, ARD = 16.0 fewer in 1000, 95% CI 18.6-12.1 fewer, NNT=62), but may make little-to-no difference in the risk of hip fractures among postmenopausal females. Denosumab probably makes little-to-no difference in the risk of all-cause mortality or health-related quality of life among postmenopausal females. Evidence in males is limited to two trials (1 zoledronic acid, 1 denosumab); in this population, zoledronic acid may make little-to-no difference in the risk of hip or clinical fragility fractures, and evidence for all-cause mortality is very uncertain. The evidence for treatment with denosumab in males is very uncertain for all fracture outcomes (hip, clinical fragility, clinical vertebral) and all-cause mortality. There is moderate certainty evidence that treatment causes a small number of patients to experience a non-serious adverse event, notably non-serious gastrointestinal events (e.g., abdominal pain, reflux) with alendronate (50 RCTs, n = 22,549, ARD = 16.3 more in 1000, 95% CI 2.4-31.3 more, [number needed to treat for an additional harmful outcome] NNH = 61) but not with risedronate; influenza-like symptoms with zoledronic acid (5 RCTs, n = 10,695, ARD = 142.5 more in 1000, 95% CI 105.5-188.5 more, NNH = 7); and non-serious gastrointestinal adverse events (3 RCTs, n = 8454, ARD = 64.5 more in 1000, 95% CI 26.4-13.3 more, NNH = 16), dermatologic adverse events (3 RCTs, n = 8454, ARD = 15.6 more in 1000, 95% CI 7.6-27.0 more, NNH = 64), and infections (any severity; 4 RCTs, n = 8691, ARD = 1.8 more in 1000, 95% CI 0.1-4.0 more, NNH = 556) with denosumab. For serious adverse events overall and specific to stroke and myocardial infarction, treatment with bisphosphonates probably makes little-to-no difference; evidence for other specific serious harms was less certain or not available. There was low certainty evidence for an increased risk for the rare occurrence of atypical femoral fractures (0.06 to 0.08 more in 1000) and osteonecrosis of the jaw (0.22 more in 1000) with bisphosphonates (most evidence for alendronate). The evidence for these rare outcomes and for rebound fractures with denosumab was very uncertain. Younger (lower risk) females have high willingness to be screened. A minority of postmenopausal females at increased risk for fracture may accept treatment. Further, there is large heterogeneity in the level of risk at which patients may be accepting of initiating treatment, and treatment effects appear to be overestimated.

CONCLUSION

An offer of 2-step screening with risk assessment and BMD measurement to selected postmenopausal females with low prevalence of prior fracture probably results in a small reduction in the risk of clinical fragility fracture and hip fracture compared to no screening. These findings were most applicable to the use of clinical FRAX for risk assessment and were not replicated in the offer-to-screen population where the rate of response to mailed screening questionnaires was low. Limited direct evidence on harms of screening were available; using study data to provide estimates, there may be a moderate degree of overdiagnosis of high risk for fracture to consider. The evidence for younger females and males is very limited. The benefits of screening and treatment need to be weighed against the potential for harm; patient views on the acceptability of treatment are highly variable.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO): CRD42019123767.

Association between height loss and mortality in the general population

Height loss is caused by osteoporosis, vertebral fractures, disc reduction, postural changes, and kyphosis. Marked long-term height loss is reportedly associated with cardiovascular disease and mortality in the elderly. The present study investigated the relationship between short-term height loss and the risk of mortality using the longitudinal cohort data of the Japan Specific Health Checkup Study (J-SHC). Included individuals were aged 40 years or older and received periodic health checkups in 2008 and 2010. The exposure of interest was height loss over the 2 years, and the outcome was all-cause mortality over subsequent follow up. Cox proportional hazard models were used to examine the association between height loss and all-cause mortality. Of the 222,392 individuals (88,285 men, 134,107 women) included in this study, 1436 died during the observation period (mean 4.8 ± 1.1 years). The subjects were divided into two groups based on a cut-off value of height loss of 0.5 cm over 2 years. The adjusted hazard ratio (95% confidence interval) was 1.26 (1.13-1.41) for exposure to height loss ≥ 0.5 cm compared to height loss < 0.5 cm. Height loss ≥ 0.5 cm correlated significantly with an increased risk of mortality compared to height loss < 0.5 cm in both men and women. Even a small decrease in height over 2 years was associated with the risk of all-cause mortality and might be a helpful marker for stratifying mortality risk.

Similarities and Differences in Bone Mineral Density between Multiple Sites in the Same Individual: An Elderly Cadaveric Study

Bone mineral density (BMD) is known to vary based on various factors, and the degree of variation is site-specific. However, few studies have investigated the relationship between bone density at trabecular bone-rich and cortical bone-rich sites in the same individual. In this study, we attempted to measure BMD at multiple sites using whole-body computed tomography images taken immediately after death and to clarify the similarities and differences between skeletal sites. Additionally, we aimed to examine the factors that influence changes in BMD, such as the loading environment, bone microstructure, and the ossification process of each skeletal region. A 3D model containing BMD data of the skull, clavicle, lumbar vertebrae, and femur (neck and diaphysis) was created using computed tomography images taken immediately after the death of 60 individuals (28 men and 32 women, average age: 84.0 years) who consented to participate in the study before death. Arbitrary measurement sites were defined, and bone density was measured at each site. We found that the BMDs of all regions were negatively correlated with age, but this correlation was weaker in the skull than in other regions. The negative correlation was especially pronounced in areas with more trabecular bones in men and in areas with more cortical bones in women. Furthermore, these findings suggest that factors, such as the loading environment, bone microstructure, and the ossification process of the skeletal sites, affect the BMD. Furthermore, our results suggest that it is important to assess the BMD of cortical bone in older women.

Osteoporosis therapies and their mechanisms of action (Review)

Osteoporosis is a common disease that affects millions of patients worldwide and is most common in menopausal women. The main characteristics of osteoporosis are low bone density and increased risk of fractures due to deterioration of the bone architecture. Osteoporosis is a chronic disease that is difficult to treat; thus, investigations into novel effective therapeutic methods are required. A number of studies have focused on determining the most effective treatment options for this disease. There are several treatment options for osteoporosis that differ depending on the characteristics of the disease, and these include both well-established and newly developed drugs. The present review focuses on the various drugs available for osteoporosis, the associated mechanisms of action and the methods of administration.

Effect of Resistance Training and Diet Intake on Spleen Structure of Ovariectomized Wistar Rats

Introduction Exercise is a key factor in immunity which may be affected by a different diet intake. Thus, we aimed to analyze the effects of diet intake and resistance training on spleen structure of ovariectomized female animals.

Materials and Methods Female Wistar rats were divided into eight experimental groups: sedentary and nonovariectomized animals plus vegetable protein diet (CVS) or animal protein diet (CAS); trained and nonovariectomized rats plus vegetable protein diet (CVT) or animal protein diet (CT); sedentary and ovariectomized groups plus vegetable protein diet (VOS) or animal protein diet (AOS); and trained and ovariectomized animals plus vegetable protein diet (VOT) or animal protein diet (AOT).

Results Groups submitted to both animal protein diet and resistance training, mainly ovariectomized groups, presented a great variability of collagen fibers type III, white pulp, and follicle structure in relation to the other spleen constituents.

Conclusion Resistance training with a vegetable protein diet may play a key factor to maintain spleen’s immune responses across age. However, animal protein diet is suggested to decrease spleen’s immune activity.

Assessment of fecal Akkermansia muciniphila in patients with osteoporosis and osteopenia: a pilot study

OBJECTIVES

Osteoporosis is characterized by slow deterioration in bone mass and disruption of its structure, leading to an increased risk of bone fractures. Gut microbiota plays an important role in the transport and absorption of nutrients needed for bone health. Akkermansia muciniphila is one of the gut microbiota members that its beneficial role in prevention of metabolic disorder was suggested. The aim of the current pilot study was the assessment of fecal A. muciniphila in patients with osteoporosis and osteopenia.

METHODS

A total of 36 subjects including eight with osteoporosis (three men and five women), eight with osteopenia (two men and six women), and 20 normal controls (six men and 14 women) were selected. Microbial genome was extracted from fresh stool samples. The bacterial load was determined by quantitative real-time PCR using 16S rRNA specific primers.

RESULTS

The participants' mean age in the osteoporosis, osteopenia and control groups were 61.71, 45 and 45.05 years, respectively. The majority of osteoporosis patients were post-menopause women, while in osteopenia group was pre-menopause. There were significant differences in terms of age, T-score, Z-score, and menopause among groups (P value < 0.05). The presence of A. muciniphila was higher in the healthy group compared to osteopenia group; however, these differences were not statistically significant.

CONCLUSIONS

In conclusion, however, there was no statistically significant difference between the study groups; it seems that the load of A. muciniphila may be related to bone health. Further in vivo and in vitro studies are needed to investigate the immunological and biochemical pathways.

Development of Metabolic Syndrome Decreases Bone Mineral Density T-Score of Calcaneus in Foot in a Large Taiwanese Population Follow-Up Study

Studies have suggested that there may be common pathogenic pathways linking osteoporosis and metabolic syndrome (MetS) due to the multiple risk factors for atherosclerotic cardiovascular disease caused by MetS. However, results on the association between MetS and bone health are inconsistent and sometimes contradictory. In this study, we aimed to investigate the associations between the effects of MetS risk factors and bone mineral density (BMD) T-score in a longitudinal study of 27,033 participants from the Taiwan Biobank with a follow-up period of 4 years. BMD of the calcaneus was measured in the non-dominant foot using ultrasound in the Taiwanese population. The overall prevalence rates of MetS were 16.7% (baseline) and 21.2% (follow-up). The participants were stratified into four groups according to the status of MetS (no/yes at baseline and follow-up). We investigated associations between MetS and its five components (baseline, follow-up) with BMD ΔT-score and found that the (no, yes) MetS group, (no, yes) abdominal obesity group, (no, yes) hypertriglyceridemia group, and (no, yes) low high-density lipoprotein (HDL) cholesterol group had the lowest ΔT-score. Furthermore, in the (no, yes) MetS group, high Δwaist circumference (p = 0.009), high Δtriglycerides (p = 0.004), low ΔHDL cholesterol (p = 0.034), and low Δsystolic blood pressure (p = 0.020) were significantly associated with low ΔT-score, but Δfasting glucose was not. In conclusion, in this large population-based cohort study, our data provide evidence that the development of MetS is strongly associated with increased rates of BMD loss in the Taiwanese population. This suggests that the prevention of MetS should be taken into consideration in the prevention of osteoporosis in the Taiwanese population.

Coexistence of metabolic syndrome and osteopenia associated with social inequalities and unhealthy lifestyle among postmenopausal women in South Korea: the 2008 to 2011 Korea National Health and Nutritional Examination Survey (KNHANES)

OBJECTIVE

The prevalence of metabolic syndrome (MetS) and osteoporosis (OP) among postmenopausal women has been rapidly increasing. We examined the associations between socioeconomic status-related factors, unhealthy lifestyle, and the coexistence of MetS and osteopenia or OP.

METHODS

One thousand nine hundred ninety-one postmenopausal women aged 45 to 65 years were used to select a representative sample of the civilian, noninstitutionalized South Korean population from the 2008 to 2011 Korea National Health and Nutrition Examination Survey data. Women were grouped as neither MetS nor OP (normal), MetS, OP, and both MetS and OP (MetS + OP). Socioeconomic status (education, household income, place of residence, employment status), health-related behaviors (physical activity, alcohol consumption, smoking), and diet-related factors (intake of nutrients and food groups, eating habits, food insecurity) were obtained. Logistic regression models were used to examine the odds ratio (OR) and 95% confidence interval (CI).

RESULTS

The prevalence of MetS + OP was 32.5%. The average number of MetS risk factors in MetS + OP was 3.5, higher than that of normal and OP groups (P < 0.001). Bone mineral density at all sites was significantly lower in MetS + OP than normal and MetS groups (P < 0.001). Also, calcium, phosphorus, vitamin A, riboflavin, and niacin levels were lowest in the MetS + OP group compared with the three other groups (P < 0.05). After controlling for covariates, low-income and low-education women were more likely to have MetS + OP (OR 1.97, 95% CI 1.04-3.72); high-income and high-education group was 70% less likely to have MetS + OP (OR 0.30, 95% CI 0.10-0.86) compared with the middle-income and middle-education group.

CONCLUSIONS

Social inequalities might be powerful contributors in Korean postmenopausal women with coexistence of MetS and OP. Therefore, social and political perspective approaches are required in this population for prevention and treatment of MetS and OP. Future studies should explore to find controllable factors and thereby improve health status in postmenopausal women.

Cumulative network meta-analyses, practice guidelines, and actual prescriptions for postmenopausal osteoporosis: a meta-epidemiological study

We compared the cumulative network meta-analyses with the recommendations in postmenopausal osteoporosis practice guidelines and actual prescribing practices in the USA. There was no apparent discrepancy between guideline recommendations and drug prescribing rankings, with the exception of vitamin D and calcium, when we used cumulative NMAs as references.

PURPOSE

To compare the results of cumulative network meta-analyses (NMAs) with the recommendations in postmenopausal osteoporosis practice guidelines and actual prescribing practices in the USA.

METHODS

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus were searched to retrieve randomized controlled trials (RCTs) in July 2017. The Agency for Healthcare Research and Quality's National Guideline Clearinghouse and associated society websites were searched to retrieve guidelines in June 2018. We used the Medical Expenditure Panel Survey (MEPS) to analyze prescription data from 1996 to 2015. Two independent investigators selected eligible RCTs. One investigator selected potential eligible guidelines, which were confirmed by another investigator. Two independent investigators extracted data from included RCTs. One investigator extracted recommendations from guidelines, which were confirmed by another investigator. (Registration: UMIN000031894) RESULTS: We analyzed data from 1995, 2000, 2005, 2010, and 2015. We chose hip fracture as the primary outcome of cumulative NMAs. We included 51 trials, 17 guidelines, and 5099 postmenopausal osteoporosis patients from the MEPS. Bisphosphonate, including alendronate, and combination of vitamin D and calcium (vDCa) were consistently recommendable from an efficacy viewpoint in NMAs and recommended in guidelines. Alendronate was the most prescribed drug (more than 30% over the observation period); however, vDCa was seldom prescribed. The maximum proportion was 5.3% from 2011 to 2015.

CONCLUSIONS

In postmenopausal osteoporosis, there was no apparent discrepancy between guideline recommendations and drug prescribing rankings, with the exception of vDCa, when we used cumulative NMAs as references.

Sharing Pathological Mechanisms of Insomnia and Osteoporosis, and a New Perspective on Safe Drug Choice

Lack of adequate sleep has become increasingly common in our 24/7 modern society. Reduced sleep has significant health consequences including metabolic and cardiovascular disorders, and mental problems including depression. In addition, although the increase in life expectancy has provided a dream of longevity to humans, the occurrence of osteoporosis is a big obstacle to this dream for both male and female. It is known that insomnia and bone health problems, which are very critical conditions in human life, interestingly, share a lot of pathogenesis in recent decades. Nevertheless, due to another side effects of the synthetic drugs being taken for the treatment of insomnia and osteoporosis, patients have substantial anxiety for the safety of drugs with therapeutic expectation. This review examines the pathogenesis shared by sleep and osteoporosis together and herbal medicine, which has recently been shown to be safe and efficacious in the treatment of both diseases other than synthetic drugs. We suggestions for how to treat osteoporosis. These efforts will be the first step toward enabling patients to have comfortable and safe prescriptions through a wide selection of therapeutic agents in the future.

Cumulative network-meta-analyses, practice guidelines and actual prescriptions of drug treatments for postmenopausal osteoporosis: a study protocol for cumulative network meta-analyses and meta-epidemiological study

INTRODUCTION

Cumulative network meta-analysis (NMA) is a method to provide a global comparison of multiple treatments with real-time update to evidence users. Several studies investigated the ranking of cumulative NMA and the recommendations of practice guidelines. However, to the best of our knowledge, no study has evaluated the cumulative NMA ranking and prescription patterns. Here, we present a protocol for a meta-epidemiological investigation to compare the results of cumulative NMA with the recommendations in postmenopausal osteoporosis practice guidelines and with the actual prescriptions.

METHOD AND ANALYSIS

We will use the data of primary trials from the upcoming postmenopausal osteoporosis clinical practice guideline of the Endocrine Society. We will conduct cumulative NMA using all eligible trials and generate hierarchy of treatment rankings by using the surface under the cumulative ranking curve. We will search practice guidelines in relevant society websites. Two review authors will extract the practice recommendations. We will use data from the Medical Expenditures Panel Survey, a US representative sample of the non-institutionalised population, to determine the prescription patterns.

ETHICS AND DISSEMINATION

Because all data will be retrieved from public databases, institutional review board approval is not required. We will publish our findings in a peer-reviewed journal and present key findings at conferences.

TRIAL REGISTRATION NUMBER

UMIN000031894: Pre-results.

Identification of Steroidogenic Components Derived From Gardenia jasminoides Ellis Potentially Useful for Treating Postmenopausal Syndrome

Estrogen-stimulating principles have been demonstrated to relieve postmenopausal syndrome effectively. Gardenia jasminoides Ellis (GJE) is an herbal medicine possessing multiple pharmacological effects on human health with low toxicity. However, the therapeutic effects of GJE on the management of postmenopausal syndrome and its mechanism of action have not been fully elucidated. In this study, network pharmacology-based approaches were employed to examine steroidogenesis under the influence of GJE. In addition, the possibility of toxicity of GJE was ruled out and four probable active compounds were predicted. In parallel, a chromatographic fraction of GJE with estrogen-stimulating effect was identified and nine major compounds were isolated from this active fraction. Among the nine compounds, four of them were identified by network pharmacology, validating the use of network pharmacology to predict active compounds. Then the phenotypic approaches were utilized to verify that rutin, chlorogenic acid (CGA) and geniposidic acid (GA) exerted an estrogen-stimulating effect on ovarian granulosa cells. Furthermore, the results of target-based approaches indicated that rutin, CGA, and GA could up-regulate the FSHR-aromatase pathway in ovarian granulosa cells. The stimulation of estrogen production by rat ovarian granulosa cells under the influence of the three compounds underwent a decline when the follicle-stimulating hormone receptor (FSHR) was blocked by antibodies against the receptor, indicating the involvement of FSHR in the estradiol-stimulating activity of the three compounds. The effects of the three compounds on estrogen biosynthesis- related gene expression level were further confirmed by Western blot assay. Importantly, the MTT results showed that exposure of breast cancer cells to the three compounds resulted in reduction of cell viability, demonstrating the cytotoxicity of the three compounds. Collectively, rutin, chlorogenic acid and geniposidic acid may contribute to the therapeutic potential of GJE for the treatment of postmenopausal syndrome.

Proceedings of the 2017 Santa Fe Bone Symposium: Insights and Emerging Concepts in the Management of Osteoporosis

The 18th Annual Santa Fe Bone Symposium was held on August 4-5, 2017, in Santa Fe, New Mexico, USA. The symposium convenes health-care providers and clinical researchers to present and discuss clinical applications of recent advances in research of skeletal diseases. The program includes lectures, oral presentations by endocrinology fellows, case-based panel discussions, and breakout sessions on topics of interest, with emphasis on participation and interaction of all participants. Topics included the evaluation and treatment of adult survivors with pediatric bone diseases, risk assessment and management of atypical femur fractures, nonpharmacologic strategies in the care of osteoporosis, and skeletal effects of parathyroid hormone with opportunities for therapeutic intervention. Management of skeletal complications of rheumatic diseases was discussed. Insights into sequential and combined use of antiresorptive agents were presented. Individualization of patient treatment decisions when clinical practice guidelines may not be applicable was covered. Challenges and opportunities with osteoporosis drug development were discussed. There was an update on progress of Bone Health TeleECHO (Bone Health Extension for Community Healthcare Outcomes), a teleconferencing strategy for sharing knowledge and expanding capacity to deliver best-practice skeletal health care.

Calcium Supplementation in Clinical Practice: A Review of Forms, Doses, and Indications

Most Americans do not meet the adequate intake (AI) for calcium; calcium supplements can help meet requirements. Calcium supplementation has been found to be beneficial for bone health in children, young adults, and menopausal women. In addition to calcium, vitamin D is necessary for bone health and is generally deficient in the industrialized world. Calcium from carbonate and citrate are the most common forms of calcium supplements. Calcium carbonate, the most cost-effective form, should be taken with a meal to ensure optimal absorption. Calcium citrate can be taken without food and is the supplement of choice for individuals with achlorhydria or who are taking histamine-2 blockers or protein-pump inhibitors. Calcium lactate and calcium gluconate are less concentrated forms of calcium and are not practical oral supplements. Research on hydroxyapatite as a source of calcium is limited, so this form of calcium is not recommended. The maximum dose of elemental calcium that should be taken at a time is 500 mg. U.S. Pharmacopeia-verified calcium supplements meet vigorous manufacturing and quality requirements. Absorption from calcium-fortified beverages varies and in general is not equal to that of milk. Potential adverse effects of calcium supplementation include gastrointestinal complaints. Renal calculi in most studies have not been associated with calcium supplementation. The risk of advanced and fatal prostate cancer has been associated with calcium intakes from food or supplements in amounts >1500 mg/d.

The Radiology of Osteoporotic Vertebral Fractures Redux

When a low-energy fracture occurs, then osteoporosis has progressed to the point of bony structural failure. Because vertebral fractures are the commonest type of osteoporotic fracture, the correct identification of them becomes important for diagnosis, risk estimation, and management. However, there are no uniformly agreed criteria for their diagnosis. The purpose of this review was to examine the diagnostic radiological strategies available and suggest a coherent approach to diagnosis. Diagnosis had come to focus on comparative changes in vertebral dimensions. However, it has become apparent that mild reductions in vertebral height are of uncertain implication. The importance of structural damage in diagnosis has become recognized in parallel. Relative reductions in vertebral height may not be a necessary nor sufficient criterion by which to diagnose a fracture.

Epigenetic Control of Skeletal Development by the Histone Methyltransferase Ezh2

Epigenetic control of gene expression is critical for normal fetal development. However, chromatin-related mechanisms that activate bone-specific programs during osteogenesis have remained underexplored. Therefore, we investigated the expression profiles of a large cohort of epigenetic regulators (>300) during osteogenic differentiation of human mesenchymal cells derived from the stromal vascular fraction of adipose tissue (AMSCs). Molecular analyses establish that the polycomb group protein EZH2 (enhancer of zeste homolog 2) is down-regulated during osteoblastic differentiation of AMSCs. Chemical inhibitor and siRNA knockdown studies show that EZH2, a histone methyltransferase that catalyzes trimethylation of histone 3 lysine 27 (H3K27me3), suppresses osteogenic differentiation. Blocking EZH2 activity promotes osteoblast differentiation and suppresses adipogenic differentiation of AMSCs. High throughput RNA sequence (mRNASeq) analysis reveals that EZH2 inhibition stimulates cell cycle inhibitory proteins and enhances the production of extracellular matrix proteins. Conditional genetic loss of Ezh2 in uncommitted mesenchymal cells (Prrx1-Cre) results in multiple defects in skeletal patterning and bone formation, including shortened forelimbs, craniosynostosis, and clinodactyly. Histological analysis and mRNASeq profiling suggest that these effects are attributable to growth plate abnormalities and premature cranial suture closure because of precocious maturation of osteoblasts. We conclude that the epigenetic activity of EZH2 is required for skeletal patterning and development, but EZH2 expression declines during terminal osteoblast differentiation and matrix production.

Factors affecting bone mineral density in postmenopausal women

This study aimed to determine the relationship between bone mineral density (BMD) and demographic, biochemical, and clinical features according to BMD measurement sites. The results indicated that BMD correlates negatively with menopause duration, parity, and history of fractures but positively correlates with obesity, physical activity, education, and serum ferritin.

PURPOSE/INTRODUCTION

Osteoporosis (OP) is an important cause of morbidity and mortality in the elderly people. The impacts of various factors on bone mineral density (BMD) differ across diverse population. We hypothesized that the influences of factors which affect BMD vary according to BMD measurement sites. The aim of this study was to determine the relationship between BMD in the femoral neck (FN) and lumbar spine (LS) with some common clinical, demographic, and biochemical parameters in postmenopausal women.

METHODS

In this cross-sectional case-control study, all postmenopausal women of the Amirkola Health and Ageing Project (AHAP) who performed bone densitometry were included. BMD at FN and LS was measured by DXA method. Data regarding clinical, demographic, and biochemical characteristics were provided. OP was diagnosed by the International Society for Clinical Densitometry criteria. Pearson correlation and multivariate regression analyses with simultaneous adjustment were performed to determine relationship.

RESULTS

Five hundred thirty-seven women with mean age of 67.9 ± 6.7 years and mean menopause duration (MD) of 15.8 ± 5.1 years were studied. MD correlated negatively with FN-BMD and LS-BMD g/cm(2) (r = -0.405, p = 0.001 and r = -0.217, p = 0.001). Body mass index (BMI) correlated positively with FN and LS-BMD g/cm(2) (r = 0.397, p = 0.001 and r = 0.311, p = 0.001). The association of MD with risk of FN-OP was stronger than LS-OP. Obesity and metabolic syndrome (MS) and higher serum ferritin reduced the risk of OP at both LS and FN similarly, whereas the impacts of parity, prior fracture, high level of education, and physical activity were significantly different across BMD measurement sites.

CONCLUSION

The results of this study indicated a significant association between OP and MD, obesity, parity, MS, history of fracture, serum ferritin, level of education, and physical activity. However, the direction and the strength of association varied across BMD measurement sites.

Regulators of G protein signaling 12 promotes osteoclastogenesis in bone remodeling and pathological bone loss

Regulators of G protein signaling (Rgs) have pivotal roles in controlling various cellular processes, such as cell differentiation. How Rgs proteins regulate osteoclast (OC) differentiation, function and bone homeostasis is poorly understood. It was previously demonstrated that Rgs12, the largest protein in the Rgs family, is predominantly expressed in OCs and regulates OC differentiation in vitro. To further understand the role and mechanism of Rgs12 in OC differentiation and bone diseases in vivo, we created OC-targeted Rgs12 knockout mice by using inducible Mx1-Cre and CD11b-Cre. Deletion of Rgs12 in hematopoietic cells or specifically in OC precursors resulted in increased bone mass with decreased OC numbers. Loss of Rgs12 impaired OC differentiation and function with impaired Ca(2+) oscillations and reduced nuclear factor of activated T cells (NFAT) 2 expression. The introduction of wild-type osteoblasts did not rescue the defective osteoclastogenesis. Ectopic expression of NFAT2 rescued defective OC differentiation in CD11b;Rgs12(fl/fl) cells and promoted normal OC differentiation. Moreover, deletion of Rgs12 significantly inhibited pathological osteoclastogenesis and bone destruction in Rgs12-deficient mice that were subjected to ovariectomy and lipodysaccharide for bone loss. Thus our findings demonstrate that Rgs12 is an important regulator in OC differentiation and function and identify Rgs12 as a potential therapeutic target for osteoporosis and inflammation-induced bone loss.

An overview on the treatment of postmenopausal osteoporosis

Osteoporosis is a worldwide health problem related to the aging of the population, and it is often underdiagnosed and undertreated. It is related to substantial morbidity, mortality and impairment of the quality of life. Estrogen deficiency is the major contributing factor to bone loss after menopause. The lifetime fracture risk at 50 years of age is about 50% in women. The aim of the treatment of osteoporosis is to prevent fractures. Non-pharmacological treatment involves a healthy diet, prevention of falls, and physical exercise programs. Pharmacological treatment includes calcium, vitamin D, and active medication for bone tissue such, as anti-resorptives (i.e., SERMs, hormonal replacement therapy, bisphosphonates, denosumab), bone formers (teriparatide), and mixed agents (strontium ranelate). Bisphosphonates (alendronate, risedronate, ibandronate, and zoledronate) are the most used anti-resorptive agents for the treatment of osteoporosis. Poor compliance, drug intolerance, and adverse effects can limit the benefits of the treatment. Based on the knowledge on bone cells signaling, novel drugs were developed and are being assessed in clinical trials.

Detective value of historical height loss and current height/knee height ratio for prevalent vertebral fracture in Japanese postmenopausal women

Vertebral fracture (VFx) is associated with various co-morbidities and increased mortality. In this paper, we have studied the detective value of height loss for VFx using two indices; historical height loss (HHL) which is the difference between the maximal height, and the current height (CH), and CH/knee height (KH) ratio. One-hundred and fifty-one postmenopausal women visiting the outpatient clinic of orthopaedics were studied for their CH, self-reported maximal height, KH, and radiographically diagnosed VFx number(s). VFx was present in 41.1 % of the subjects. Multiple regression analyses revealed that the number of prevalent fractures was a significant predictor of HHL and CH/KH ratio. Receiver operator characteristic curve analysis has shown that for HHL, the area under the curve (AUC) with their 95 %CI in the parentheses was 0.84 (0.77, 0.90), 0.88 (0.83, 0.94), and 0.91 (0.86, 0.96) for ≥ 1, ≥ 2, and ≥ 3 fractures, respectively. For the presence of ≥ 1 VFx, the cut-off value was 4.0 cm (specificity 79 %; sensitivity 79 %). Regarding the CH/KH ratio, AUC was 0.73 (0.65, 0.82), 0.85 (0.78, 0.93), and 0.91 (0.86, 0.96) for ≥ 1, ≥ 2, and ≥ 3 fractures, respectively. For the presence of ≥ 1 VFx, the cut-off value was 3.3 (specificity 47 %; sensitivity 91 %). Both cut-off values for HHL and CH/KH ratio had high negative predictivity across the wide range of theoretical VFx prevalence. Thus, HHL and CH/KH were both good detectors of VFx. Our data would be the basis to determine the cut-off value for the screening or case finding of subjects with VFx.

Novel ligands balance estrogen receptor β and α agonism for safe and effective suppression of the vasomotor response in the ovariectomized female rat model of menopause

Vasomotor thermo-dysregulation (hot flashes) are an often debilitating symptom of menopause. Effective treatment is achieved primarily through activation of the estrogen receptor (ER)α with estrogens but is also associated with increased risk for breast and uterine cancer. In this study, we have tested novel compounds lacking the B ring of 17-hydroxy-β-estradiol (E2) (A-CD compounds) with differing ratios of ERα:ERβ binding affinities for the ability to reduce diurnal/nocturnal tail-skin temperatures (TSTs) in the ovariectomized female rat menopausal hot flash model. Normal mammary tissue expresses the predominantly antiproliferative ERβ. Therefore, we hypothesized that a preferential ERβ agonist with fractional ERα activity would safely reduce TSTs. The A-CD compound, L17, is a preferential ERβ agonist that has a ratio of ERβ:ERα binding affinity relative to E2 of 9.3 (where ERβ:ERα for E2, 1.0). In the ovariectomized rat, daily administration of low doses (1 mg/kg) of the A-CD compound TD81 (ERα:ERβ relative affinity, 15.2) was ineffective in temperature regulation, whereas L17 showed a trend toward TST reduction. Both E2 and the A-CD compound, TD3 (ERβ:ERα relative affinity, 5.0), also reduced TSTs but had marked proliferative effects on mammary and uterine tissues. At 2 mg/kg, L17 strongly reduced TSTs even more effectively than E2 but, importantly, had only minimal effect on uterine weight and mammary tissues. Both E2- and L17-treated rats showed similar weight reduction over the treatment period. E2 is rapidly metabolized to highly reactive quinones, and we show that L17 has 2-fold greater metabolic stability than E2. Finally, L17 and E2 similarly mediated induction of c-fos expression in neurons within the rat thermoregulatory hypothalamic median preoptic nucleus. Thus, the A-CD compound, L17, may represent a safe and effective approach to the treatment of menopausal hot flashes.

Age as a predictor of osteoporotic fracture compared with current risk-prediction models

OBJECTIVE

To compare several fracture risk-prediction models and their predictive values.

METHODS

Women older than age 49 years were sent for dual-energy X-ray absorptiometry screening between January 2007 and March 2009. Data collection included multiple osteoporosis risk factors. The ability to identify fractures was analyzed and compared using the North American Menopause Society 2006 and 2010 Position Statements, The Fracture Risk Assessment Tool, along with age alone. The area under the curve (AUC) comparison with chance (AUC 0.50) and paired AUC comparisons between models were used to investigate the efficacy of each model in predicting osteoporotic fractures.

RESULTS

Among the 615 women studied, with mean (standard deviation) age of 61.4 (8.3) years and 94.5% being white, 15 have experienced a fracture. All screening approaches were significantly better than chance at predicting fractures. Paired comparisons of the detection ability of fracture prediction models showed no significant differences. Age alone was a significant predictor for fracture (AUC 0.79, 95% confidence interval [CI] 0.67-0.91, P<.001) with the optimal cutoff age of 65 years, which was associated with a sensitivity (95% CI) of 80% (77-83%) and specificity (95% CI) of 73% (70-77%). Compared with young postmenopausal women (younger than 65 years), the odds ratio (95% CI) of fractures in older women (65 years or older) is 10.2 (2.32-44.97). In addition, when age was added, it significantly increased the AUC of each model.

CONCLUSION

These data suggest that all current screening modalities are effective in predicting fracture but not significantly better than age alone. Age should be considered carefully while evaluating patients for osteoporosis screening and treatment.

LEVEL OF EVIDENCE

II.

Decreased bone mineral density and periodontal management

The definition of osteoporosis has evolved beyond low bone mineral density to include impaired bone morphology and matrix properties. As such, the subsequent bone density insufficiencies extend beyond the skeletal risks of fracture and have implications for oral health management patients. As our population ages there is a worldwide increase in the risk of decreased bone mineral density and its subsequent morbidity. This makes age an independent risk factor for fracture and decreased bone mineral density. Multiple examinations and diagnostic tests are currently used in combination to develop an algorithm to assess osteoporotic risk. Oral health care professionals should follow these principles and caution should be used in applying a single independent assessment to determine a patient's osteoporotic or bone metabolism risk. Therapeutic approaches for osteoporosis are often divided into nonpharmacological interventions and pharmacological therapies. The periodontist and other oral health care professionals should have a full understanding of the therapeutic options, benefits and implementation of preventive therapies. Bone turnover is a coupled event of bone formation and bone resorption and it is the imbalance of this homeostasis that results in osteoporosis. Based on this uncoupling of bone resorption and formation, osteoporosis or decreased bone mineral density and osteopenia, may be a risk factor for alveolar bone loss in periodontitis. The role of prevention and maintenance with a history of periodontitis and oesteopenia extends beyond biofilm control and should include management of bone mineral density. The chronic periodontal infection in a patient with osteopenia may place the patient at greatly increased risk for alveolar bone loss, gingival recession and root caries. A key component in the management is the oral health professional's knowledge of the interrelationship between skeletal health and periodontal health.

Influence of number of deliveries and total breast-feeding time on bone mineral density in premenopausal and young postmenopausal women

OBJECTIVES

Pregnancy and lactation have been associated with decline in bone mineral density (BMD). It is not clear if there is a full recovery of BMD to baseline. This study sought to determine if pregnancy or breast-feeding or both have a cumulative effect on BMD in premenopausal and early postmenopausal women.

STUDY DESIGN

We performed single-center cohort analysis. Five hundred women aged 35-55 years underwent routine BMD screening from February to July 2011 at a tertiary medical center. Patients were questioned about number of total full-term deliveries and duration of breast-feeding and completed a background questionnaire on menarche and menopause, smoking, dairy product consumption, and weekly physical exercise. Weight and height were measured. Dual-energy X-ray absorptiometry was used to measure spinal, dual femoral neck, and total hip BMD.

MAIN OUTCOME MEASURES

Associations between background characteristics and BMD values were analyzed.

RESULTS

Sixty percent of the women were premenopausal. Mean number of deliveries was 2.5 and mean duration of breast-feeding was 9.12 months. On univariate analysis, BMD values were negatively correlated with patient age (p=0.006) and number of births (p=0.013), and positively correlated with body mass index (p<0.001). On multiple (adjusted) logistic regression analysis, prolonged breast-feeding duration, but not number of deliveries, was significantly correlated to a low BMD (p=0.008). An effect was noted only in postmenopausal women. The spine was the most common site of BMD decrease.

CONCLUSIONS

Prolonged breast-feeding may have a deleterious long-term effect on BMD and may contribute to increased risk of osteoporosis later in life.

Association of homocysteine, vitamin B12, and folate with bone mineral density in postmenopausal women: a meta-analysis

BACKGROUND

The relationship of homocysteine (Hcy), folate, and vitamin B12 with bone mineral density (BMD) has been investigated in postmenopausal women. However, the relationship is still controversial.

PURPOSE

To evaluate the association of Hcy, folate, vitamin B12 and BMD in postmenopausal women with a meta-analysis.

METHODS

We searched for all published articles indexed in Medline (1950-2012), Embase (1974-2012), and China National Knowledge Infrastructure (1994-2012). Any case-control or cohort study relating to Hcy, vitamin B12, folate, and BMD was included, and the data were extracted independently by two reviewers. Criteria for inclusion were the assessment of Hcy, vitamin B12, folate, and BMD in postmenopausal women as outcomes. We performed this meta-analysis with Review Manager 5.1 software. Odds ratios and 95 % confidence intervals (CI) were used to evaluate the results.

RESULTS

Six eligible studies were selected for meta-analysis. Our analysis suggested that vitamin B12 and Hcy levels were significantly higher in postmenopausal osteoporosis (PMOP) group than that in controls (P = 0.007, <0.05; 95 % CI 3.06-19.38 and P = 0.0003, <0.05; 95 % CI 0.75-2.52, respectively). Folate level was lower in PMOP group than that in controls, but this difference was not statistically significant (P = 0.09, 95 % CI -3.33 to 0.25).

CONCLUSIONS

Hcy and vitamin B12, but not folate, were related to BMD in PMOP. Extra vitamin B12 may not play a protective role for osteoporosis in postmenopausal women. Future studies are needed to confirm them, especially the relationship between increased vitamin B12 and BMD.

Effects of electroacupuncture on bone mineral density, oestradiol level and osteoprotegerin ligand expression in ovariectomised rabbits

OBJECTIVES

To investigate the effects of electroacupuncture (EA) on the oestradiol level, bone mineral density and osteoprotegerin ligand (OPGL) expression, and to explore whether EA might be a complementary method to prevent and treat osteoporosis.

METHODS

A total of 21 New Zealand rabbits were randomly divided into three groups: a normal control (NC) group undergoing no surgery or EA; an ovariectomised (OVX) group, in which rabbits were ovariectomised but did not receive EA; an EA group, in which rabbits were ovariectomised and treated with EA. Acupuncture was applied at ST35, BL20 and BL23 points bilaterally. EA (10 Hz, 2 mA) was applied bilaterally at BL20 and BL23 for 30 min a day for 14 days. After 14 days, all animals were killed. OPGL expression level was determined by immunohistochemistry. Blood serum levels of oestradiol were measured by ELISA and bone mineral density was detected by dual-energy x-ray absorptiometry.

RESULTS

After ovariectomy, the bone mineral density and oestradiol level decreased significantly in the OVX group compared with the NC group (p=0.001), whereas the OPGL expression level increased. After EA, the bone mineral density and oestradiol level increased compared with the OVX group (p=0.049 and p=0.012, respectively). The OPGL level OPGL level in the EA group was lower than that in the OVX group (p=0.022).

CONCLUSIONS

EA restored bone mineral density towards normal and was associated with increased plasma oestradiol level and reduced OPGL expression in an ovariectomised rabbit model of osteoporosis.

Evidence-based risk assessment and recommendations for physical activity: arthritis, osteoporosis, and low back pain

We systematically reviewed the safety of physical activity (PA) for people with arthritis, osteoporosis, and low back pain. We searched PubMed, MEDLINE, Sport Discus, and the Cochrane Central Register of Controlled Trials (1966 through March 2008) for relevant articles on PA and adverse events. A total of 111 articles met our inclusion criteria. The incidence for adverse events during PA was 3.4%-11% (0.06%-2.4% serious adverse events) and included increased joint pain, fracture, and back pain for those with arthritis, osteoporosis, and low back pain, respectively. Recommendations were based on the Appraisal of Guidelines for Research and Evaluation, which applies Levels of Evidence based on type of study ranging from high-quality randomized controlled trials (Level 1) to anecdotal evidence (Level 4) and Grades from A (strong) to C (weak). Our main recommendations are that (i) arthritic patients with highly progressed forms of disease should avoid heavy load-bearing activities, but should participate in non-weight-bearing activities (Level 2, Grade A); and (ii) patients with osteoporosis should avoid trunk flexion (Level 2, Grade A) and powerful twisting of the trunk (Level 3, Grade C); (iii) patients with acute low back pain can safely do preference-based PA (i.e., PA that does not induce pain), including low back extension and flexion (Level 2, Grade B); (iv) arthritic patients with stable disease without progressive joint damage and patients with stable osteoporosis or low back pain can safely perform a variety of progressive aerobic or resistance-training PAs (Level 2, Grades A and B). Overall, the adverse event incidence from reviewed studies was low. PA can safely be done by most individuals with musculoskeletal conditions.

Effects of hormone therapy on the endometrium in postmenopausal women: a one year randomized trial of low dose oral estradiol in association with a levonorgestrel-releasing intrauterine system or drospirenone

OBJECTIVES: to compare the endometrial effects and uterine bleeding patterns associated with treatment using (1) levonorgestrel-releasing intrauterine system (LNG-IUS) and estradiol (1 mg/day, p.o.) or (2) orally administered drospirenone (2 mg/day) andestradiol (1 mg/day). METHODS: thirty-four patients (aged 52.53 ± 4.44 in the LNG-IUS group and 53.15 ± 4.018 in the DRSP group) were randomized. The severity of menopausal symptoms was evaluated using the Kupperman index every three months. Transvaginal ultrasound, hysteroscopy and histological evaluation were repeated after 12 months. During this period, patients kept menstrual calendars. All categorical variables were described as percentages. Variables were tested for normal distribution and Student's t test was applied for independent samples and ANOVA forrepeated measures when appropriate. Data were considered to be significant when p<0.05. RESULTS: slight vaginal bleeding was reported in the first month of treatment by 53.3% of patients from the LNG-IUS/estradiol group compared with 7.7% of patients from the drospirenone/estradiol group. There were no differences in endometrial thickness between the two groups throughout the study period. End-of-study histological findings showed atrophic endometrium in 53.3% of patients in the LNG-IUS/estradiol group compared with 76.9% of patients in the drospirenone/estradiol group. CONCLUSIONS: our results suggest good endometrial protection with both HT regimens.

Association of the MTHFR C677T polymorphism and bone mineral density in postmenopausal women: a meta-analysis

Osteoporosis is a condition characterized by low bone mineral density (BMD) and micro-architectural changes in the bone tissue. The risk of osteoporosis is partly determined by genetic factors. The role of C677T polymorphism of methylenetetrahydrofolate reductase (MTHFR) gene has been investigated in postmenopausal osteoporosis. However, the relationship between MTHFR polymorphism and BMD is still controversial. We carried out a meta-analysis of 5,833 subjects to evaluate the association of MTHFR and BMD in postmenopausal women. Databases of MEDLINE, Web of Science, Scopus and CNKI were retrieved for all publications relating to MTHFR polymorphism and BMD in postmenopausal women. Five eligible studies were selected for meta-analysis. All these articles studied the association of MTHFR polymorphism and BMD of the femoral neck and lumbar spine in postmenopausal women. Our analysis suggested that postmenopausal women with the TT genotype had lower femoral neck BMD than the women with the CC/CT genotype, and the weighted mean difference (WMD) was -0.01 g/cm(2) [95% confidence interval (CI): (-0.01, -0.01), P < 0.01]. However, BMD of the lumbar spine of postmenopausal women with the TT genotype was not significantly different from that of women with the CC/CT genotype. In the random effects model, the WMD between the TT and TC/CC genotype was -0.01 g/cm(2) [95% CI: (-0.04, 0.01), P = 0.32]. The C677T polymorphism of the MTHFR gene is associated with BMD of the femoral neck in postmenopausal women. Women with the TT genotype of the MTHFR gene have lower BMD, suggesting that the TT genotype may be a risk factor for postmenopausal osteoporosis.

Nuclear receptors in bone physiology and diseases

During the last decade, our view on the skeleton as a mere solid physical support structure has been transformed, as bone emerged as a dynamic, constantly remodeling tissue with systemic regulatory functions including those of an endocrine organ. Reflecting this remarkable functional complexity, distinct classes of humoral and intracellular regulatory factors have been shown to control vital processes in the bone. Among these regulators, nuclear receptors (NRs) play fundamental roles in bone development, growth, and maintenance. NRs are DNA-binding transcription factors that act as intracellular transducers of the respective ligand signaling pathways through modulation of expression of specific sets of cognate target genes. Aberrant NR signaling caused by receptor or ligand deficiency may profoundly affect bone health and compromise skeletal functions. Ligand dependency of NR action underlies a major strategy of therapeutic intervention to correct aberrant NR signaling, and significant efforts have been made to design novel synthetic NR ligands with enhanced beneficial properties and reduced potential negative side effects. As an example, estrogen deficiency causes bone loss and leads to development of osteoporosis, the most prevalent skeletal disorder in postmenopausal women. Since administration of natural estrogens for the treatment of osteoporosis often associates with undesirable side effects, several synthetic estrogen receptor ligands have been developed with higher therapeutic efficacy and specificity. This review presents current progress in our understanding of the roles of various nuclear receptor-mediated signaling pathways in bone physiology and disease, and in development of advanced NR ligands for treatment of common skeletal disorders.

Comparison of Vitamin D Label Dosing Recommendations to North American National Guidelines

Supplementation with vitamin D has become increasingly popular over the past decade, and numerous organizations have developed recommendations for the appropriate intake of vitamin D. Vitamin D supplements come in a variety of formulations and strengths and vary in their directions for use. This study was designed to compare vitamin D label dosing information with the recommendations in North American guidelines. A systematic search was conducted to identify 62 single-ingredient vitamin D products of which 1000 IU was the most common strength. Assessment of North American guidelines found recommended vitamin D dosing to range from 400 to 1000 IU daily, depending on age. Twenty-four (39%) of the products recommended a maximum dose within the range of 400 to 1000 IU daily. Thirty-eight (61%) and 19 (31%) products recommended maximum doses more than 1000 IU daily and 2000 IU daily, respectively. Labeled dosing recommendations of commercially available vitamin D supplements are largely inconsistent with North American recommendations.

Healthy diet to prevent cardiovascular diseases and osteoporosis: the experience of the 'ProSa' project

The ProSa (PROmozione e tutela della SAlute) Project ('Health Promotion Project') is a workplace programme geared to promote health among the Roman staff of the National Research Council of Italy. 789 employees of both genders (450 men, 339 women) have participated in the cardiovascular prevention programme (screening, computerized calculation of the risk level, dietary and pharmacological intervention) and 245 women have participated in the osteoporosis programme (calcaneal ultrasonometer test, dietary and pharmacological intervention). Menopause increases the risk of cardiovascular diseases and osteoporosis. In order to lower dietary fat content, dietary intake of calcium and vitamin D could be reduced. However, supplementation of both may not be necessary if we follow an integrated dietary approach. Therefore, for women in menopause with mixed hyperlipidaemia (hypercholesterolaemia and/or hypertriglyceridaemia) and/or overweight/obesity, dietary intervention was aimed at promoting the choice of foods low in fats and rich in calcium based on a list of recommended products distributed to all the participants. The dietary intervention was accompanied by a programme of regular physical activity with adequate exposure to sunlight. By following a balanced diet it is possible to improve the prognosis not only for hyperlipidaemic patients, but also for patients with signs of osteopaenia or osteoporosis.

Documenting the use of calcium supplements with oral bisphosphonates

OBJECTIVE

Patients receiving an oral bisphosphonate for treatment of osteopenia or osteoporosis without adequate calcium intake are not optimally treated. Physicians prescribing bisphosphonates may not consistently document calcium supplementation recommendations.

DESIGN

This is a retrospective chart review of osteoporotic or osteopenic outpatients with an active prescription for an oral bisphosphonate. This cross-sectional study was designed to determine the point prevalence of calcium supplementation recommendations by physicians.

SETTING

Academic family medicine outpatient clinics.

PATIENTS

Of the 1,229 patients with osteoporosis or osteopenia, 425 patients had an active prescription for an oral bisphosphonate and were included in the study.

INTERVENTIONS

The active/inactive medication list and physician clinic notes in the electronic medical record were reviewed for documentation regarding calcium.

MAIN OUTCOME MEASURES

The primary endpoint was the percentage of patients on bisphosphonates also receiving calcium. The secondary endpoint was the identification of demographic characteristics associated with lower use of calcium.

RESULTS

The patient sample was 94% female, 69% white, with a mean body mass index of 27, and mean age of 72 years. Of the 425 patients, 387 (91.1%) were taking calcium or had a documented recommendation for calcium supplementation. Of the demographic characteristics evaluated, only age was statistically significantly different, with an average age of 76 years in the calcium group and 66 years of age in the noncalcium group.

CONCLUSION

In this study, 91% of outpatients who were prescribed a bisphosphonate also were taking calcium or had it recommended to them. The only statistically significant difference between groups was greater age for those who received calcium.

Impact of a pharmacist-directed intervention in postmenopausal women after fracture

PURPOSE

The impact of decentralized clinical pharmacy services on the implementation of appropriate care in postmenopausal women with a recent history of a fracture was assessed.

METHODS

Women 67 years of age or older with a documented fracture between January 1 and December 31, 2007, were identified in two geographic regions. At the intervention site, a decentralized clinical-pharmacy-based osteoporosis management service (CPOMS) intervened on postmenopausal women following fracture, while the comparison group utilized a centralized registered nurse to manage this population. In both groups, interventions included initiation of either osteoporosis medication or bone mineral density (BMD) screening.

RESULTS

Of the 827 women in the CPOMS group, 65% (523) initiated a medication for osteoporosis or completed BMD screening within 6 months of the fracture, compared with 46% (139) of the 302 women in the comparison group (p < 0.001; cumulative incidence ratio [CIR], 1.75; 95% confidence interval [CI], 1.44-2.12). CPOMS patients were nearly twice as likely as comparison group patients to purchase osteoporotic medications (42% [347 of 827] versus 24% [73 of 302]; CIR, 1.89; 95% CI, 1.50-2.40) and equally likely to undergo BMD testing (35% [289 of 827] versus 31% [94 of 302]; CIR, 1.13; 95% CI, 0.91-1.39). Both interventions achieved results substantially higher than national averages. Of patients receiving a medication and continuous membership for 12 months, adherence was also significantly higher in the CPOMS group (46% [39 of 291] versus 28% [20 of 71], respectively; p = 0.007).

CONCLUSION

An integrated pharmacist-run osteoporosis management service demonstrated a substantial increase in the rate of osteoporosis drug initiation among post-menopausal women who experienced a fracture compared with a centrally located nurse-run service. BMD screening rates did not significantly differ between groups.

Usefulness of estimated height loss for detection of osteoporosis in women

PURPOSE

This study was done to examine the threshold value of estimated height loss at which the risk of osteoporosis increases and to verify its discriminative ability in the detection of osteoporosis.

METHODS

It was conducted based on epidemiological descriptive methods on 732 Korean women at a public healthcare center in Seoul between July and November 2010. ANOVA, Pearson correlation, logistic regression analysis and receiver operating characteristics (ROC) curve were used for data analysis.

RESULTS

There was an age-related correlation between bone mineral density (lumbar spine: F=37.88, p<.001; femur: F=54.27, p<.001) and estimated height loss (F=27.68, p<.001). Estimated height loss increased significantly with decreasing bone mineral density (lumbar spine: r=-.23, p<.001; femur: r=-.34, p<.001). The odds ratio for the point at which the estimated height loss affects the occurrence of osteoporosis was found to increase at a cut-off value of 2 cm and the area under ROC curve was .71 and .82 in lumbar spine and femur, respectively.

CONCLUSION

The optimal cut-off value of the estimated height loss for detection of osteoporosis was 2 cm. Height loss is therefore a useful indicator for the self-assessment and prognosis of osteoporosis.

Height loss starting in middle age predicts increased mortality in the elderly

The purpose of this study was to determine the mortality risk among Japanese men and women with height loss starting in middle age, taking into account lifestyle and physical factors. A total of 2498 subjects (755 men and 1743 women) aged 47 to 91 years old underwent physical examinations during the period 1994 to 1995. Those individuals were followed for mortality status through 2003. Mortality risk was estimated using an age-stratified Cox proportional hazards model. In addition to sex, adjustment factors such as radiation dose, lifestyle, and physical factors measured at the baseline--including smoking status, alcohol intake, total cholesterol, blood pressure, and diagnosed diseases--were used for analysis of total mortality and mortality from each cause of death. There were a total of 302 all-cause deaths, 46 coronary heart disease and stroke deaths, 58 respiratory deaths including 45 pneumonia deaths, and 132 cancer deaths during the follow-up period. Participants were followed for 20,787 person-years after baseline. Prior history of vertebral deformity and hip fracture were not associated with mortality risk. However, more than 2 cm of height loss starting in middle age showed a significant association with all-cause mortality among the study participants (HR = 1.76, 95% CI 1.31 to 2.38, p = 0.0002), after adjustment was made for sex, attained age, atomic-bomb radiation exposure, and lifestyle and physical factors. Such height loss also was significantly associated with death due to coronary heart disease or stroke (HR = 3.35, 95% CI 1.63 to 6.86, p = 0.0010), as well as respiratory-disease death (HR = 2.52, 95% CI 1.25 to 5.22, p = 0.0130), but not cancer death. Continuous HL also was associated with all-cause mortality and CHD- or stroke-caused mortality. Association between height loss and mortality was still significant, even after excluding persons with vertebral deformity. Height loss of more than 2 cm starting in middle age was an independent risk factor for cardiovascular and respiratory-disease mortality among the elderly, even after adjusting for potential risk factors.

Cost-effectiveness of different screening strategies for osteoporosis in postmenopausal women

BACKGROUND

The best strategies to screen postmenopausal women for osteoporosis are not clear.

OBJECTIVE

To identify the cost-effectiveness of various screening strategies.

DESIGN

Individual-level state-transition cost-effectiveness model.

DATA SOURCES

Published literature.

TARGET POPULATION

U.S. women aged 55 years or older.

TIME HORIZON

Lifetime.

PERSPECTIVE

Payer.

INTERVENTION

Screening strategies composed of alternative tests (central dual-energy x-ray absorptiometry [DXA], calcaneal quantitative ultrasonography [QUS], and the Simple Calculated Osteoporosis Risk Estimation [SCORE] tool) initiation ages, treatment thresholds, and rescreening intervals. Oral bisphosphonate treatment was assumed, with a base-case adherence rate of 50% and a 5-year on/off treatment pattern.

OUTCOME MEASURES

Incremental cost-effectiveness ratios (2010 U.S. dollars per quality-adjusted life-year [QALY] gained).

RESULTS OF BASE-CASE ANALYSIS

At all evaluated ages, screening was superior to not screening. In general, quality-adjusted life-days gained with screening tended to increase with age. At all initiation ages, the best strategy with an incremental cost-effectiveness ratio (ICER) of less than $50,000 per QALY was DXA screening with a T-score threshold of -2.5 or less for treatment and with follow-up screening every 5 years. Across screening initiation ages, the best strategy with an ICER less than $50,000 per QALY was initiation of screening at age 55 years by using DXA -2.5 with rescreening every 5 years. The best strategy with an ICER less than $100,000 per QALY was initiation of screening at age 55 years by using DXA with a T-score threshold of -2.0 or less for treatment and then rescreening every 10 years. No other strategy that involved treatment of women with osteopenia had an ICER less than $100,000 per QALY. Many other strategies, including strategies with SCORE or QUS prescreening, were also cost-effective, and in general the differences in effectiveness and costs between evaluated strategies was small.

RESULTS OF SENSITIVITY ANALYSIS

Probabilistic sensitivity analysis did not reveal a consistently superior strategy.

LIMITATIONS

Data were primarily from white women. Screening initiation at ages younger than 55 years were not examined. Only osteoporotic fractures of the hip, vertebrae, and wrist were modeled.

CONCLUSION

Many strategies for postmenopausal osteoporosis screening are effective and cost-effective, including strategies involving screening initiation at age 55 years. No strategy substantially outperforms another.

PRIMARY FUNDING SOURCE

National Center for Research Resources.

Consensus statements on osteoporosis diagnosis, prevention, and management in the Philippines

OBJECTIVE

The consensus statements were developed to assist healthcare practitioners in providing optimal care to postmenopausal individuals at risk for osteoporosis and fragility fractures in the local setting.

METHODOLOGY

The Technical Review Committee formed by the Osteoporosis Society of the Philippines Foundation Inc. in cooperation with the Philippine Orthopedic Association drafted, retrieved available published evidence, and appraised important issues on osteoporosis and fragility fractures. The Appraisal of Guidelines Research and Evaluation instrument was used to appraise published guidelines while a systematic way of validating the quality of evidence and the level of recommendation was done using the GRADE system. A multidisciplinary panel of experts and stakeholders in an en banc meeting conferred and approved the recommendations.

RESULTS AND CONCLUSION

There were five key issues on preventive, seven on diagnostic, nine on therapeutic aspects of osteoporosis with four other surgical concerns on fragility fractures. All were approved by a panel of stakeholders through a majority vote. These statements will best inform the clinicians and the specialists including orthopedic surgeons and general care practitioners on issues of postmenopausal Filipino women at risk for osteoporosis and fragility fractures.