Osteoporosis prevention and management: nonpharmacologic and lifestyle options. Clin Obstet Gynecol. 2013;56:703-710. [PMID: 24047936 DOI: 10.1097/grf.0b013e3182a9d15a]

Scopolamine mitigates oophorectomy-induced osteoporosis: potential mechanisms and direct effects on bone structure

The aim of our research is to investigate the therapeutic effects of scopolamine (SCO) on osteoporosis and to explore the underlying mechanism. To study osteoporosis, we established an ovariectomy (OVX) model. The rats were divided into four groups: sham operation, OVX, OVX+SCO, and OVX+SCO+ML385 (Nrf2 inhibitor). ELISA, Realtime PCR, Western blot, and kits were utilised to assess the expression of related proteins and substances. The OVX rats exhibited significant weight gain, reduced bone volume, destruction of trabecular and cortical bone microstructure, decreased expression of ALP, OCN, OPN, COL1A1, Runx2, Nrf2 proteins, and CAT, SOD, GST, GPX levels while increased expression of TRAP protein and ROS levels. SCO was able to restore these indices in OVX rats, while ML385 blocked the effects of SCO. In conclusion, SCO inhibits oxidative stress response to exert therapeutic effects on osteoporosis by activating the Nrf2 signalling pathway.

The effect of cannabinoids on single-level lumbar arthrodesis outcomes in a rat model

BACKGROUND CONTEXT

The opioid epidemic is a public health crisis affecting spine care and pain management. Medical marijuana is a potential nonopioid analgesic yet to be studied in the surgical setting since its effects on bone healing are not fully understood. Studies have demonstrated analgesic and potentially osteoinductive properties of cannabinoids with endocannabinoid receptor expression in bone tissue.

PURPOSE

We hypothesize that tetrahydrocannabinol (THC) and cannabidiol (CBD) will not decrease bone healing in spinal fusion.

STUDY DESIGN

Seventy-eight adult Sprague-Dawley rats were used for this study. Utilizing allogenic bone grafts (6 donor rats), posterolateral inter-transverse lumbar fusion at the L4-L5 level was performed. The animals were equally divided into four treatment groups, each receiving 0.1 ml intraperitoneal injections weekly as follows: placebo (saline), 5 mg/kg THC, 5 mg/kg CBD, and a combination of 5 mg/kg THC and 5mg/kg CBD (Combo).

METHODS

Callus tissue was harvested 2- and 8-weeks postsurgery for qPCR assessment to quantify changes in the expression of osteogenic genes. Manual palpation was done to assess the strength of the L4-L5 arthrodesis on all rats. μCT image-based callus analysis and histology were performed. One-way ANOVA followed by post hoc comparisons was performed.

RESULTS

μCT demonstrated no significant differences. Treatment groups had slightly increased bone volume and density compared to control. qPCR at 2 weeks indicated downregulated RANKL/OPG ratios skewing towards osteogenesis in the CBD group, with the THC and CBD+THC groups demonstrating a downward trend (p>.05). ALPL, BMP4, and SOST were significantly higher in the CBD group, with CTNNB1 and RUNX2 also showing an upregulating trend. The CBD group showed elevation in Col1A1 and MMP13. Data at eight weeks showed ALPL, RUNX2, BMP4, and SOST were downregulated for all treatment groups. In the CBD+THC group, RANK, RANKL, and OPG were downregulated. OPG downregulation reached significance for the THC and CBD+THC group compared to saline. Interestingly, the RANKL/OPG ratio showed upregulation in the CBD and CBD+THC groups. RANKL showed upregulation in the CBD group. At 2 and 8 weeks, the CBD treatment group showed superior histological progression, increasing between time points.

CONCLUSION

This study demonstrates that CBD and THC have no adverse effect on bone healing and the rate of spinal fusion in rats. Osteogenic factors were upregulated in the CBD-treated groups at 2 weeks, which indicates a potential for bone regeneration. In this group, compared to control, the RANKL/OPG ratio at the early healing phase demonstrates the inhibition of osteoclast differentiation, enhancing bone formation. Interestingly, it shows promoted osteoclast differentiation at the later healing phase, enhancing bone remodeling. This aligns with the physiological expectation of a lower ratio in the early phases and a higher ratio in the later remodeling phases.

CLINICAL SIGNIFICANCE

CBD and THC showed no inhibitory effects on bone healing in a spinal fusion model. Moreover, histologic and gene expression analysis demonstrated that CBD may, in fact, enhance bone healing. Further research is needed to confirm the safe usage of THC and CBD in the postoperative setting following spinal fusions.

Matters We Metric Vs. Metrics that Matter

Introduction

Geriatric fracture is a pressing global health issue, marked by elevated mortality and morbidity rates and escalating health care costs. The evolving health care system from fee-for-service to quality-based reimbursement has led to externally driven reward and reimbursement systems that may not account for the complexity of caring for older adults with fracture.

Significance

The aim of this review is to highlight the need for a shift towards meaningful metrics that impact geriatric fracture care and to issue a call to action for all medical societies to advocate for national reimbursement and ranking systems that focus on metrics that truly matter.

Results

Traditional metrics, while easier to capture, may not necessarily represent high quality care and may even have unintentional adverse consequences. For example, the focus on reducing length of stay may lead to older patients being discharged too early, without adequately addressing pain, constipation, or delirium. In addition, a focus on mortality may miss the opportunity to deliver compassionate end-of-life care. Existing geriatric fracture care metrics have expanded beyond traditional metrics to include assessment by geriatricians, fracture prevention, and delirium assessments. However, there is a need to further consider and develop patient-focused metrics. The Age-Friendly Health Initiative (4 Ms), which includes Mobility, Medication, Mentation, and what Matters is an evidence-based framework for assessing and acting on critical issues in the care of older adults. Additional metrics that should be considered include an assessment of nutrition and secondary fracture prevention.

Conclusion

In the realm of geriatric fracture care, the metrics currently employed often revolve around adherence to established guidelines and are heavily influenced by financial considerations. It is crucial to shift the paradigm towards metrics that truly matter for geriatric fracture patients, recognizing the multifaceted nature of their care and the profound impact these fractures have on their lives.

The association between different impact exercises and osteoporosis: an analysis of data from the Taiwan biobank

Osteoporosis is a prevalent condition marked by reduced bone density and an elevated risk of fractures, especially among postmenopausal women. Exercise plays a crucial role in preventing and managing osteoporosis, with weight-bearing and impact exercises being particularly effective in enhancing bone density and mitigating disease risk. This study investigated the relationship between various types of impact exercises and osteoporosis using data from the Taiwan Biobank (TWB). The study sample comprised 5,123 individuals without osteoporosis and 1,770 individuals with the condition. Student's t-test and logistic regression analyses were utilized to assess the associations between exercise types and osteoporosis risk. Results indicated that high-impact exercise significantly reduced the likelihood of developing osteoporosis compared to no exercise (odds ratio; OR = 0.573, 95% CI: 0.406-0.810, P = 0.002). Conversely, low-impact exercises did not show a significant overall association with osteoporosis (OR = 1.160, 95% CI: 0.932-1.445, P = 0.184). Stratified analysis by sex revealed that high-impact exercise was protective against osteoporosis in men (OR = 0.391, 95% CI: 0.202-0.755, P = 0.005), but not significantly so in women (OR = 0.671, 95% CI: 0.438-1.027, P = 0.066). These findings suggest that high-impact exercise is associated with a reduced risk of osteoporosis, particularly among Taiwanese men aged 30 to 70.

Association between daily consumption of spicy food and bone mineral density in middle-aged and older adults: a cross-sectional study

Background: Many studies have reported the effects of spicy food on human health, but no studies have been conducted on the impact of long-term spicy food consumption on bone mineral density (BMD). This study aimed to investigate the impact of daily consumption of spicy food on BMD in the population aged 50 years and older. Methods: This cross-sectional study was conducted from 2020 to 2022 in Jiangxi Province, China. This study investigated the differences in BMD between non-consumers and daily spicy food consumers in adults aged 50-85 years. A multiple linear regression model was used to investigate the association between spicy food consumption and BMD of the total lumbar spine (LS), femoral neck (FN), and total hip, as well as biochemical markers of bone metabolism (BMBM) levels. Results: The results showed that daily consumption of spicy food was negatively associated with total LS BMD (β = -0.013, P = 0.015). Subgroup analyses showed this negative association was more pronounced among smokers and drinkers compared to non-smokers (β: -0.006 vs. -0.042; P for interaction <0.05) and non-drinkers (β: -0.004 vs. -0.037; P for interaction <0.05). In addition, according to the daily frequency of spicy food consumption, the daily spicy food consumers were categorized into one meal per day, two meals per day, and three meals per day groups. Further analysis revealed that the negative association between spicy food and total LS BMD was progressively stronger as the frequency of daily consumption of spicy food increased (P for trend <0.05). For BMBM, daily consumption of spicy food was positively associated with serum PINP levels and negatively associated with serum Ca and serum Mg levels. Conclusions: Our study suggested that daily consumption of spicy food was associated with lower LS BMD in middle-aged and older Chinese adults, and this association was more pronounced in the smoking and drinking populations. The adverse effects of spicy food on LS BMD become progressively stronger with increasing frequency of daily consumption of spicy food. In addition, daily consumption of spicy food was associated with higher PINP levels and lower serum Ca and Mg levels.

Assessing the effects of probiotic supplementation, single strain versus mixed strains, on femoral mineral density and osteoblastic gene mRNA expression in rats

INTRODUCTION

Osteoporosis is a significant health concern characterized by weak and porous bones, particularly affecting menopausal women aged 50 and above, leading to increased risk of hip fractures and associated morbidity and mortality.

MATERIALS AND METHODS

We conducted a study to assess the efficacy of single-strain versus mixed-strain probiotic supplementation on bone health using an ovariectomy (OVX) rat model of induced bone loss. The probiotics evaluated were Lactobacillus helveticus (L. helveticus), Bifidobacterium longum (B. longum), and a combination of both. Rats were divided into five groups: SHAM (Control negative), OVX (Control positive), OVX +L. helveticus, OVX + B. longum, and OVX + mixed L. helveticus and B. longum. Daily oral administration of probiotics at 10^8-10^9 CFU/mL began two weeks post-surgery and continued for 16 weeks.

RESULTS

Both single-strain and mixed-strain probiotic supplementation upregulated expression of osteoblastic genes (BMP- 2, RUNX-2, OSX), increased serum osteocalcin (OC) levels, and improved bone formation parameters. Serum C-terminal telopeptide (CTX) levels and bone resorption parameters were reduced. However, the single-strain supplementation demonstrated superior efficacy compared to the mixed-strain approach.

CONCLUSION

Supplementation with B. longum and L. helveticus significantly reduces bone resorption and improves bone health in OVX rats, with single-strain supplementation showing greater efficacy compared to a mixed-strain combination. These findings highlight the potential of probiotics as a therapeutic intervention for osteoporosis, warranting further investigation in human studies.

Tuberculosis and osteoporotic fracture risk: development of individualized fracture risk estimation prediction model using a nationwide cohort study

Purpose

Tuberculosis (TB) is linked to sustained inflammation even after treatment, and fracture risk is higher in TB survivors than in the general population. However, no individualized fracture risk prediction model exists for TB survivors. We aimed to estimate fracture risk, identify fracture-related factors, and develop an individualized risk prediction model for TB survivors.

Methods

TB survivors (n = 44,453) between 2010 and 2017 and 1:1 age- and sex-matched controls were enrolled. One year after TB diagnosis, the participants were followed-up until the date of fracture, death, or end of the study period (December 2018). Cox proportional hazard regression analyses were performed to compare the fracture risk between TB survivors and controls and to identify fracture-related factors among TB survivors.

Results

During median 3.4 (interquartile range, 1.6-5.3) follow-up years, the incident fracture rate was significantly higher in TB survivors than in the matched controls (19.3 vs. 14.6 per 1,000 person-years, p < 0.001). Even after adjusting for potential confounders, TB survivors had a higher risk for all fractures (adjusted hazard ratio 1.27 [95% confidence interval 1.20-1.34]), including hip (1.65 [1.39-1.96]) and vertebral (1.35 [1.25-1.46]) fractures, than matched controls. Fracture-related factors included pulmonary TB, female sex, older age, heavy alcohol consumption, reduced exercise, and a higher Charlson Comorbidity Index (p < 0.05). The individualized fracture risk model showed good discrimination (concordance statistic = 0.678).

Conclusion

TB survivors have a higher fracture risk than matched controls. An individualized prediction model may help prevent fractures in TB survivors, especially in high-risk groups.

The association between body mass index and osteoporosis in a Taiwanese population: a cross-sectional and longitudinal study

This study investigates the correlation between body mass index (BMI) and osteoporosis utilizing data from the Taiwan Biobank. Initially, a comprehensive analysis of 119,009 participants enrolled from 2008 to 2019 was conducted to assess the association between BMI and osteoporosis prevalence. Subsequently, a longitudinal cohort of 24,507 participants, initially free from osteoporosis, underwent regular follow-ups every 2-4 years to analyze the risk of osteoporosis development, which was a subset of the main cohort. Participants were categorized into four BMI groups: underweight (BMI < 18.5 kg/m2), normal weight (18.5 kg/m2 ≤ BMI < 24 kg/m2), overweight (24 kg/m2 ≤ BMI < 27 kg/m2), and obese groups (BMI ≥ 27 kg/m2). A T-score ≤ - 2.5 standard deviations below that of a young adult was defined as osteoporosis. Overall, 556 (14.1%), 5332 (9.1%), 2600 (8.1%) and 1620 (6.7%) of the participants in the underweight, normal weight, overweight and obese groups, respectively, had osteoporosis. A higher prevalence of osteoporosis was noted in the underweight group compared with the normal weight group (odds ratio [OR], 2.20; 95% confidence interval [95% CI], 1.99 to 2.43; p value < 0.001) in multivariable binary logistic regression analysis. Furthermore, in the longitudinal cohort during a mean follow-up of 47 months, incident osteoporosis was found in 61 (9%), 881 (7.2%), 401 (5.8%) and 213 (4.6%) participants in the underweight, normal weight, overweight and obese groups, respectively. Multivariable Cox proportional hazards analysis revealed that the risk of incident osteoporosis was higher in the underweight group than in the normal weight group (hazard ratio [HR], 1.63; 95% CI 1.26 to 2.12; p value < 0.001). Our results suggest that BMI is associated with both the prevalence and the incidence of osteoporosis. In addition, underweight is an independent risk factor for developing osteoporosis. These findings highlight the importance of maintaining normal weight for optimal bone health.

Development of an opportunistic diagnostic prediction algorithm for osteoporosis and fragility fracture risk estimates from forearm radiographs (The OFFER1 Study)

Osteoporosis and associated fractures are an increasingly prevalent concern with an ageing population. This study reports testing of IBEX Bone Health (IBEX BH) software, applied following acquisition of forearm radiographs. IBEX Bone Health analyses the radiograph to measure areal bone mineral density (aBMD) at the examination site. A non-randomized cross-sectional study design was performed involving 261 (254 after exclusions) participants (112/142 m/f; mean age 70.8 years (SD+/-9.0); 53 with osteoporosis). They underwent posterior-anterior distal forearm radiographs; dual X-ray absorptiometry (DXA) of the wrists, hips, and lumbar spine; and questionnaires exploring clinical risk factors. IBEX Bone Health automatically identifies regions of interest (ROI) at the ultra-distal (UD) and distal third (TD) regions of the radius. Analysis investigated area under the receiver operating characteristics curve performance of IBEX BH for prediction of (i) osteoporosis (based on clinical reporting of the hip and spine DXA) and (ii) treatment recommendations by Fracture Risk Assessment Tool (FRAX) inclusive of neck of femur (NoF) areal bone mineral density (aBMD) results following National Osteoporosis Guideline Group (NOGG) guidelines. Area under the receiver operating characteristics curve for osteoporosis prediction at the UD and TD ROIs were 0.86 (99% confidence interval (CI) [0.80, 0.91]) and 0.81 (99% CI [0.75, 0.88]), respectively. Area under the receiver operating characteristics curve for treatment recommendation using FRAX inclusive of NoF aBMD at the UD and TD ROIs were 0.95 (99% CI [0.91, 1.00]) and 0.97 (99% CI [0.93,1.00]), respectively. With a matched sensitivity to FRAX (without NoF aBMD) 0.93 (99% CI [0.78, 0.99]), IBEX BH predicted at the UD and TD ROIs recommended treatment outcomes by NOGG guidelines using FRAX (with NoF aBMD) with specificity 0.89 (99% CI 0.83, 0.94]) and 0.93 (99% CI [0.87, 0.97]), respectively. This is compared with 0.60 (99% CI [0.51, 0.69]) for FRAX (without NoF aBMD). Results demonstrate the potential clinical utility of IBEX BH as an opportunistic screening tool.

Catgut embedding in acupoints combined with repetitive transcranial magnetic stimulation for the treatment of postmenopausal osteoporosis: study protocol for a randomized clinical trial

Background

To date, the clinical modulation for bone metabolism based on the neuro-bone mass regulation theory is still not popular. The stimulation of nerve systems to explore novel treatments for Postmenopausal osteoporosis (PMOP) is urgent and significant. Preliminary research results suggested that changes brain function and structure may play a crucial role in bone metabolism with PMOP. Thus, we set up a clinical trial to investigate the effect of the combination of repetitive transcranial magnetic stimulation (rTMS) and catgut embedding in acupoints (CEA) for PMOP and to elucidate the central mechanism of this neural stimulation in regulating bone metabolism.

Method

This trial is a prospective and randomized controlled trial. 96 PMOP participants will be randomized in a 1:1:1 ratio into a CEA group, an rTMS group, or a combined one. Participants will receive CEA, rTMS, or combined therapy for 3 months with 8 weeks of follow-up. The primary outcomes will be the changes in Bone Mineral Density scores, total efficiency of Chinese Medicine Symptoms before and after treatment. Secondary outcomes include the McGill Pain Questionnaire Short-Form, Osteoporosis Symptom Score, Mini-Mental State Examination, and Beck Depression Inventory-II. The leptin, leptin receptor, and norepinephrine levels of peripheral blood must be measured before and after treatment. Adverse events that occur during the trial will be recorded.

Discussion

CEA achieves brain-bone mass regulation through the bottom-up way of peripheral-central while rTMS achieves it through the top-down stimulation of central-peripheral. CEA combined with rTMS can stimulate the peripheral-central at the same time and promote peripheral bone mass formation. The combination of CEA and rTMS may play a coordinating, synergistic, and side-effect-reducing role, which is of great clinical significance in exploring better treatment options for PMOP.Clinical trial registration: https://www.chictr.org.cn/, identifier ChiCTR2300073863.

Analyzing the factors associated with efficacy among teriparatide treatment in postmenopausal women with osteoporosis

BACKGROUND

Teriparatide (TPTD) is a widely used anabolic agent for the treatment of osteoporosis. Several factors have been identified to be related to bone mineral density (BMD) increase in anti-osteoporosis treatment with other agents; however, there has been no systematic analysis to summarize the associated determinants of BMD reaction to daily teriparatide treatment.

METHODS

In this retrospective study, we performed a comprehensive investigation involving not only clinical data but also several relevant lifestyle factors to be examined for their potential contribution to BMD response. This post-hoc analysis included 258 post-menopaused patients with osteoporosis who received TPTD at 20 µg/day for 12 months. Univariate and multivariate analyses were conducted to distinguish the response variables of lumbar spine (LS) BMD transformation, the principal outcome measure of efficacy, from the baseline at 12 months.

RESULTS

Twelve months of TPTD treatment resulted in an absolute 0.39 ± 0.37 increase in T-score of LS BMD. Gastrointestinal disease, prior bisphosphonate or glucocorticoid treatment, no vitamin K2 supplementation, low levels of serum 25(OH)D and PINP, weak increment of PINP and β-CTX at 3 months, unhealthy lifestyle (excessive smoking, tea, coffee, and drinking), vegetarian diet pattern, low ALT level, and high BMD at baseline were determined by univariate analyses to be related to the weak reaction of TPTD treatment (P < 0.10). In the multiple regression model, postmenopausal women with vitamin K2 supplementation, higher baseline serum 25(OH)D level, and higher PINP concentration at 3 months indicated a good reaction of LS BMD at 12 months (P < 0.05). Patients with gastrointestinal disease, prior bisphosphonate and glucocorticoid treatment, vegetarian diet pattern, and higher baseline BMD were significantly more likely to have a lower absolute LS BMD response compared to patients without these characteristics (P < 0.05). Further analysis confirmed the negative effect of unhealthy lifestyle on TPTD treatment.

CONCLUSION

Our results emphasize the significance of a comprehensive assessment of clinical or lifestyle-related characteristics of postmenopausal women with osteoporosis in the management of TPTD therapy in routine care.

Research progress of targeted therapy regulating Th17/Treg balance in bone immune diseases

Rheumatoid arthritis (RA) and postmenopausal osteoporosis (PMOP) are common bone-immune diseases. The imbalance between helper (Th17) and regulatory T cells (Tregs) produced during differentiation of CD4+ T cells plays a key regulatory role in bone remodelling disorders in RA and PMOP. However, the specific regulatory mechanism of this imbalance in bone remodelling in RA and PMOP has not been clarified. Identifying the regulatory mechanism underlying the Th17/Treg imbalance in RA and PMOP during bone remodelling represents a key factor in the research and development of new drugs for bone immune diseases. In this review, the potential roles of Th17, Treg, and Th17/Treg imbalance in regulating bone remodelling in RA and PMOP have been summarised, and the potential mechanisms by which probiotics, traditional Chinese medicine compounds, and monomers maintain bone remodelling by regulating the Th17/Treg balance are expounded. The maintenance of Th17/Treg balance could be considered as an therapeutic alternative for the treatment of RA and PMOP. This study also summarizes the advantages and disadvantages of conventional treatments and the quality of life and rehabilitation of patients with RA and PMOP. The findings presented her will provide a better understanding of the close relationship between bone immunity and bone remodelling in chronic bone diseases and new ideas for future research, prevention, and treatment of bone immune diseases.

Effect of Lifestyle Modification Intervention Programme on Bone Mineral Density among Postmenopausal Women with Osteoporosis

Objectives

Osteoporosis is one of the major public health problems worldwide among postmenopausal osteoporotic women. Lifestyle modification interventions along with pharmacotherapy help to revert bone loss and prevent complications.

Methods

A randomised controlled trial was conducted at Kasturba Hospital, Manipal from January 2019 to December 2021 among postmenopausal women with osteoporosis. The postmenopausal women who attended the osteoporosis clinic and were within the age group of 45-65 years, could speak and understand English or Kannada and whose bone mineral density (BMD) score was between -1 and -3 were included in the study. The total sample size of the study was 120 with 60 in each of the experimental and control groups. After obtaining informed consent, a stratified block randomisation method was used to allocate the participants to intervention and control groups. The BMD was monitored by the portable ultrasound densitometer by a technician at the outpatient departments. The baseline information was collected by a structured demographic questionnaire. Intervention group participants received a lifestyle modification intervention program (LMIP) whereas the control group received standard regular care from the physician. Follow-up was done at three and six months.

Results

The results revealed that the increase in the BMD median score among the experimental group was from -2.2 (-2.5- -1.8) to -1.5 (-1.8- -0.65) whereas in the control group, it was from -2.3 (-2.6- -1.9) to -2.0 (-2.4- -1.5). The results of the Mann Whitey U test showed a statistical significance between the intervention and control groups in the post-test after six months (U = 505.5; P <0.05). Wilcoxon signed rank test showed a significant change in both the intervention and control groups from pre-test to post-test I (3 months) and post-test II (6 months; P <0.001).

Conclusion

The lifestyle modification intervention was found to be effective in improving the bone health status of postmenopausal women. Hence it is very important to integrate it into regular therapy.

A clinical prediction model for 10-year risk of self-reported osteoporosis diagnosis in pre- and perimenopausal women

A machine learning model using clinical, laboratory, and imaging data was developed to predict 10-year risk of menopause-related osteoporosis. The resulting predictions, which are sensitive and specific, highlight distinct clinical risk profiles that can be used to identify patients most likely to be diagnosed with osteoporosis.

PURPOSE

The aim of this study was to incorporate demographic, metabolic, and imaging risk factors into a model for long-term prediction of self-reported osteoporosis diagnosis.

METHODS

This was a secondary analysis of 1685 patients from the longitudinal Study of Women's Health Across the Nation using data collected between 1996 and 2008. Participants were pre- or perimenopausal women between 42 and 52 years of age. A machine learning model was trained using 14 baseline risk factors-age, height, weight, body mass index, waist circumference, race, menopausal status, maternal osteoporosis history, maternal spine fracture history, serum estradiol level, serum dehydroepiandrosterone level, serum thyroid-stimulating hormone level, total spine bone mineral density, and total hip bone mineral density. The self-reported outcome was whether a doctor or other provider had told participants they have osteoporosis or treated them for osteoporosis.

RESULTS

At 10-year follow-up, a clinical osteoporosis diagnosis was reported by 113 (6.7%) women. Area under the receiver operating characteristic curve of the model was 0.83 (95% confidence interval, 0.73-0.91) and Brier score was 0.054 (95% confidence interval, 0.035-0.074). Total spine bone mineral density, total hip bone mineral density, and age had the largest contributions to predicted risk. Using two discrimination thresholds, stratification into low, medium, and high risk, respectively, was associated with likelihood ratios of 0.23, 3.2, and 6.8. At the lower threshold, sensitivity was 0.81, and specificity was 0.82.

CONCLUSION

The model developed in this analysis integrates clinical data, serum biomarker levels, and bone mineral densities to predict 10-year risk of osteoporosis with good performance.

Body composition assessment in adult females with anorexia nervosa and bulimia nervosa - a cross-sectional study comparing dual-energy X-ray absorptiometry scan and isotopic dilution of deuterium

BACKGROUND

Eating disorders (EDs) compromise individuals' nutritional status, affecting among other organs and systems, bone health.

OBJECTIVE

This study aimed to assess and compare bone mineral density (BMD) from dual-energy x-ray absorptiometry (DXA) scan and deuterium (D₂O) dilution of adult females with anorexia nervosa (AN) and bulimia nervosa (BN).

METHODS

This was a cross-sectional study with 53 female participants (18-49 years) with a diagnosis of AN (N = 25) or BN (N = 28). DXA scan was performed to assess BMD, fat mass, and fat-free mass, and D₂O dilution was used to assess total body water (TBW), fat mass, and fat-free mass. Interviews/questionnaires were used to assess symptoms, illness trajectory, and physical activity. T-test, Chi-squared test, Pearson's linear correlation, linear regressions, and Bland-Altman analyses were performed, with a significance level of 5%.

RESULTS

TBW below the recommended level for adult females (≥ 45%) was more frequent in BN (60%) compared with AN (21%; P = 0.013). FMI (soft tissue only) (t-test P = 0.06), and FFMI (t-test P = 0.08) agreed between DXA scan and D₂O dilution. Only FFMI did not show systematic bias of proportion (β:-0.2, P = 0.177). The diagnosis of BN, binge-eating episodes, and physical activity in AN were associated with the differences in the methods' results. FMI was positively associated with BMD in AN, and both FMI and FFMI were positively associated with BMD in BN.

CONCLUSION

In adult females with EDs, DXA scan and D₂O dilution achieved agreement for FMI and FFMI. Changes in fat mass and fat-free mass are important in understanding the mechanisms behind bone loss in EDs. Protocols for body composition assessment in EDs can help to minimize the effect of the ED diagnosis, ED behaviors (i.e., excessive exercise and purging behaviors) and weight on the accuracy of measurements.

Cross-sectional community-based study in Saudi Arabian population with inclusion of behavioral studies of osteoporosis patients

Purpose

Osteoporosis is especially prevalent in the older population and in women. Fractures lead to many health complications, placing an enormous burden on the health system. Improved knowledge will encourage healthy practices that prevent osteoporosis and help community members avoid unhealthy lifestyles and habits. The goal of this study was to evaluate the knowledge, attitudes, and practices relating to osteoporosis among male and female students of the Jazan community.

Methods

The Jazan region has 13 governorates and a population of more than 1.5 million. For this study, 440 participants were selected from seven different governorates, and the osteoporosis knowledge assessment tool (OKAT) was used together with five background variables and some questions on attitude and practice. A Chi-squared test was implemented to identify any significant relationships between the background variables and the knowledge and practice scores. A P value of less than 0.05 was considered significant.

Results

Of the 440 participants, 53% were men and 47% women. Thirty-three percent of them held government jobs, 73% had completed university, and 50% had a monthly income of less than 5,000 riyals. Regarding the risk factors for osteoporosis, 62 (14%) smoked, 37 (8.4%) used steroids, 184 (41.8%) had a family history of osteoporosis, and 393 (89.3%) had not attended an education campaign on osteoporosis. The highest number of correct answers in the OKAT was to the question "osteoporosis increases the risk of fractures" (423, 96.1%), and the lowest number of correct answers was to the question "osteoporosis is more common in men" (60, 13.6%). Regarding protective behaviors against osteoporosis, namely physical activity, daily intake of dairy products, attending an education campaign, and background characteristics, attending an education campaign was statistically significant, with a P value of 0.003, but marital status, education level, body mass index (BMI), and occupation were not statistically significant. For the risk factors, sex was statistically significant, along with the daily soft drink intake and smoking but not with the use of steroids. Other background characteristics, such as education level and BMI, were not statistically significant as osteoporosis risk factors.

Conclusions

The participants' level of knowledge was high, and the risk factors for osteoporosis were still present together with a low level of achievement for protective measures. It is highly recommended that education campaigns be implemented to increase knowledge and encourage improved attitudes and practices.

Cirsium Setidens Water Extracts Containing Linarin Block Estrogen Deprivation-Induced Bone Loss in Mice

Osteoporosis is evident in postmenopausal women and is an osteolytic disease characterized by bone loss that further increases the susceptibility to bone fractures and frailty. The use of complementary therapies to alleviate postmenopausal osteoporosis is fairly widespread among women. Edible Cirsium setidens contains various polyphenols of linarin, pectolinarin, and apigenin with antioxidant and hepatoprotective effects. This study aimed to determine whether Cirsium setidens water extracts (CSEs), the component linarin, and its aglycone acacetin blocked ovariectomy (OVX)-induced bone loss. This study employed OVX C57BL/6 female mice as a model for postmenopausal osteoporosis. CSEs, acacetin, or linarin was orally administrated to OVX mice at a dose of 20 mg/kg for 8 weeks. Surgical estrogen loss in mice for 8 weeks reduced bone mineral density (BMD) of mouse femur and serum 17β-estradiol level and enhanced the serum receptor activator of NF-κB ligand/osteoprotegerin ratio with uterine atrophy. CSEs and linarin reversed such adverse effects and enhanced femoral BMD in OVX mice. Oral administration of CSEs and linarin attenuated tartrate-resistant acid phosphate activity and the induction of αvβ3 integrins and proton suppliers in resorption lacunae in femoral bone tissue of OVX mice. In addition, CSEs and linarin curtailed the bone levels of cathepsin K and matrix metalloproteinase-9 responsible for osteoclastic bone resorption. On the other hand, CSEs and linarin enhanced the formation of trabecular bones in estrogen-deficient femur with increased induction of osteocalcin and osteopontin. Further, treatment with CSEs and linarin enhanced the collagen formation-responsive propeptide levels in the circulation along with the increase in the tissue non-specific alkaline phosphatase level in bone exposed to OVX. Supplementing CSEs, acacetin, or linarin to OVX mice elevated the formation of collagen fibers in OVX trabecular bone, evidenced using Picrosirius red staining. Accordingly, CSEs and linarin were effective in retarding osteoclastic bone resorption and promoting osteoblastic bone matrix mineralization under OVX conditions. Therefore, linarin, which is abundant in CSEs, may be a natural compound for targeting postmenopausal osteoporosis and pathological osteoresorptive disorders.

Management of a Girl With Delayed Puberty and Elevated Gonadotropins

A girl presenting with delayed puberty and elevated gonadotropins may have a range of conditions such as Turner syndrome (TS), primary ovarian insufficiency (POI), and 46,XY disorders of sexual development (DSD). An organized and measured approach to investigation can help reach a timely diagnosis. Management of young people often requires specialist multidisciplinary input to address the endocrine and nonendocrine features of these complex conditions, as well as the psychological challenges posed by their diagnosis. Next-generation sequencing within the research setting has revealed several genetic causes of POI and 46,XY DSD, which may further facilitate an individualized approach to care of these young people in the future. Pubertal induction is required in many and the timing of this may need to be balanced with other issues specific to the condition (eg, allowing time for information-sharing in 46,XY DSD, optimizing growth in TS). Shared decision-making and sign-posting to relevant support groups from the outset can help empower young people and their families to manage these conditions. We describe 3 clinical vignettes of girls presenting with delayed puberty and hypergonadotropic amenorrhea and discuss their clinical management in the context of current literature and guidelines.

Current Status of the Diagnosis and Management of Osteoporosis

Osteoporosis has been defined as the silent disease of the 21st century, becoming a public health risk due to its severity, chronicity and progression and affecting mainly postmenopausal women and older adults. Osteoporosis is characterized by an imbalance between bone resorption and bone production. It is diagnosed through different methods such as bone densitometry and dual X-rays. The treatment of this pathology focuses on different aspects. On the one hand, pharmacological treatments are characterized by the use of anti-resorptive drugs, as well as emerging regenerative medicine treatments such as cell therapies and the use of bioactive hydrogels. On the other hand, non-pharmacological treatments are associated with lifestyle habits that should be incorporated, such as physical activity, diet and the cessation of harmful habits such as a high consumption of alcohol or smoking. This review seeks to provide an overview of the theoretical basis in relation to bone biology, the existing methods for diagnosis and the treatments of osteoporosis, including the development of new strategies.

Therapeutic Treatments for Osteoporosis-Which Combination of Pills Is the Best among the Bad?

Osteoporosis is a chronical, systemic skeletal disorder characterized by an increase in bone resorption, which leads to reduced bone density. The reduction in bone mineral density and therefore low bone mass results in an increased risk of fractures. Osteoporosis is caused by an imbalance in the normally strictly regulated bone homeostasis. This imbalance is caused by overactive bone-resorbing osteoclasts, while bone-synthesizing osteoblasts do not compensate for this. In this review, the mechanism is presented, underlined by in vitro and animal models to investigate this imbalance as well as the current status of clinical trials. Furthermore, new therapeutic strategies for osteoporosis are presented, such as anabolic treatments and catabolic treatments and treatments using biomaterials and biomolecules. Another focus is on new combination therapies with multiple drugs which are currently considered more beneficial for the treatment of osteoporosis than monotherapies. Taken together, this review starts with an overview and ends with the newest approaches for osteoporosis therapies and a future perspective not presented so far.

Application of metabolomics in osteoporosis research

Osteoporosis (OP) is a systemic disease characterized by bone metabolism imbalance and bone microstructure destruction, which causes serious social and economic burden. At present, the diagnosis and treatment of OP mainly rely on imaging combined with drugs. However, the existing pathogenic mechanisms, diagnosis and treatment strategies for OP are not clear and effective enough, and the disease progression that cannot reflect OP further restricts its effective treatment. The application of metabolomics has facilitated the study of OP, further exploring the mechanism and behavior of bone cells, prevention, and treatment of the disease from various metabolic perspectives, finally realizing the possibility of a holistic approach. In this review, we focus on the application of metabolomics in OP research, especially the newer systematic application of metabolomics and treatment with herbal medicine and their extracts. In addition, the prospects of clinical transformation in related fields are also discussed. The aim of this study is to highlight the use of metabolomics in OP research, especially in exploring the pathogenesis of OP and the therapeutic mechanisms of natural herbal medicine, for the benefit of interdisciplinary researchers including clinicians, biologists, and materials engineers.

Comparative Study of DHA with Different Molecular Forms for Ameliorating Osteoporosis by Promoting Chondrocyte-to-Osteoblast Transdifferentiation in the Growth Plate of Ovariectomized Mice

Osteoblasts play a key role in bone remodeling. Recent studies have reported that some hypertrophic chondrocytes co-expressing collagen I(Col I) and collagen X (ColX) could directly transdifferentiate into osteoblasts during endochondral ossification. However, whether nutrition intervention is beneficial to this transformation to improve osteoporosis (OP) remains unknown. In this study, ovariectomy (OVX)-induced OP mice were orally administered with docosahexaenoic acid (DHA) in different molecular forms for 13 weeks. The results showed that both DHA-triglyceride (DHA-TG) and DHA-phosphatidylcholine (DHA-PC) increased the bone mineral density and bone mineral apposition rate in ovariectomized mice, while DHA-ethyl esters (DHA-EE) had little effect. Interestingly, we found that both DHA-PC and DHA-TG increased the height of the growth plate, mainly increasing the number of hypertrophic chondrocytes. Further investigation by simultaneously labeling ColX and ColI indicated that DHA-PC and DHA-TG promoted the number of chondrocyte-transdifferentiated osteoblasts in the growth plate close to the diaphysis, in which DHA-PC performed better than DHA-TG. Apoptosis was not the only fate of hypertrophic chondrocytes. Western blot results showed that both DHA-TG and DHA-PC downregulated the Bax and cleaved-caspase3 expression and upregulated Bcl-2 expression in the growth plate, suggesting that chondrocyte apoptosis is inhibited. Runx2, the key regulator of chondrocyte-to-osteoblast transdifferentiation, was significantly increased by DHA-TG and DHA-PC, while DHA-EE had no effect on the above indicators. To our best knowledge, this is the first report that both DHA-PC and DHA-TG enhanced bone formation via promoting the chondrocyte-to-osteoblast transdifferentiation in the growth plate, contributing to the amelioration of OP. These activities depend on the molecular forms of DHA and their bioavailabilities. Our results provide guidance for the application of fish oil for bone health.

Next‑generation sequencing of miRNAs and lncRNAs from rat femur and tibia under mechanical stress

Exercise intervention has become one of the most effective methods to prevent and treat osteoporosis, which is a common age‑related disease and seriously affects the health and quality of life of the elderly. However, the molecular mechanism remains to be elucidated. The present study demonstrated the exercise‑induced promotion of osteogenic differentiation and inhibition of adipogenic differentiation in femur and tibia by establishing an animal exercise model using a treadmill exercise system. MicroRNA (miRNA/miR) and long non‑coding (lnc)RNA sequencing analyses identified 16 upregulated and two downregulated miRNAs in the exercise group, as well as 44 upregulated lncRNAs and 39 downregulated lncRNAs in the exercise group. There was increased expression of miR‑9942 and miR‑7704 in both the femur and tibia and an upregulation of miR‑30d, miR‑5100 and miR‑1260 in the femur of animals from the exercise group. In addition, four of the five most downregulated lncRNAs, including lncRNA MSTRG.2625, lncRNA MSTRG.1557, lncRNA MSTRG.691 and lncRNA MSTRG.7497, were demonstrated to be suppressed in both the femur and tibia after treadmill exercise. The results of the present study provided a valuable resource for further exploring the molecular mechanisms underlying the regulation of osteoporosis by exercise.

Health care service use and costs for a cohort of high-needs elderly diabetic patients

AIMS

To describe the impact of diabetes comorbidities on the health care services use and costs of a cohort of elderly patients with diabetes and high health care needs (HHCN), based on real-world data.

METHODS

We focused on a cohort of diabetic patients with HHCN belonging to Resource Utilization Bands 4 and 5 according to the Adjusted Clinical Group (ACG) system. Their comorbidities were assessed using the clinical diagnoses that the ACG system assigns to single patients by combining different information flows. Regression models were applied to analyze the associations between comorbidities and health care service use or costs, adjusting for age and sex.

RESULTS

Our analyses showed that all health care service usage measures (e.g. access to emergency care; number of outpatient visits) and the total annual costs and pharmacy costs are associated significantly with comorbidity class. Instead, no differences in hospitalization rates by comorbidity class were revealed.

CONCLUSION

The association between a larger number of comorbidities and higher total health care service usage and costs was seen mainly for primary care services. This underscores the need to strengthen primary care for today's aging and multimorbid population.

Impact of Hormonal Replacement Therapy on Bone Mineral Density in Premature Ovarian Insufficiency Patients

Premature ovarian insufficiency (POI) is a type of hypergonadotropic hypogonadism caused by impaired ovarian function before the age of 40. Due to the hypoestrogenism, women with POI experience a variety of health complications, including an increased risk of bone mineral density loss and developing osteopenia and osteoporosis, which poses an important problem for public health. Purpose: The aim of this study was to evaluate and compare the values of bone mineral density (BMD), T-score and Z-score within the lumbar spine (L1-L4) using the dual energy X-ray absorptiometry method. The dual-energy X-ray absorptiometry (DXA) scans described in this original prospective article were performed at the time of POI diagnosis and after treatment with sequential hormone replacement therapy (HRT). Materials and methods: This study included 132 patients with a mean age of 31.86 ± 7.75 years who had been diagnosed with idiopathic POI. The control group consisted of 17 healthy women with regular menstrual cycles, with a mean age of 23.21 ± 5.86 years. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), 17-estradiol (E2), prolactin (PRL), testosterone (T), dehydroepiandrosterone sulfate (DHEA-S), thyroid-stimulating hormone (TSH), free thyroxine (fT4), insulin, and fasting serum glucose were measured. Lumbar spine (L1-L4) BMD was assessed by means of dual-energy X-ray absorptiometry. DXA scans were performed at the time of diagnosis and following treatment with sequential hormone replacement therapy (HRT) comprised of daily oral 2 mg 17-β-estradiol and 10 mg dydrogesterone. The mean time of observation was 3 ± 2 years. Results: Patients in the POI group presented with characteristic hypergonadotropic hypogonadism. They had a significantly decreased mean lumbar spine BMD when compared to healthy controls (1.088 ± 0.14 g/cm2) vs. 1.150 ± 0.30 g/cm2) (p = 0.04) as well as a decreased T-score (0.75 ± 1.167 vs. −0.144 ± 0.82) (p = 003). There was a significant increase in BMD (1.088 ± 0.14 vs. 1.109 ± 0.14; p < 0.001), T-score (−0.75 ± 1.17 vs. −0.59 ± 1.22; p < 0.001), and Z-score (−0.75 ± 1.12 vs. −0.49 ± 1.11; p < 0.001) after the implementation of HRT when compared to pre-treatment results. Conclusions: In conclusion, this study has demonstrated that patients with POI often have decreased bone mineral density and that the implementation of HRT has a significant and positive influence on bone mass. The implementation of full-dose HRT and monitoring of bone status is particularly important in these patients.

Comparison of multimedia and printed patient education tools for patients with osteoporosis: a 6-month randomized controlled trial

We conducted a randomized controlled trial to compare the efficacy of adding a video tool to a printed booklet on osteoporosis. Both strategies were effective in increasing knowledge and decreasing decisional conflict. There was no difference in the measured outcomes between the intervention and control groups. Patient preferences and learning styles are key factors in deciding a presentation format when educating patients with osteoporosis.

INTRODUCTION

Innovative approaches to patient education about self-management in osteoporosis may improve outcomes.

METHODS

We conducted a randomized controlled trial to compare the efficacy of adding a multimedia patient education tool involving video modeling to a printed educational booklet on osteoporosis. Participants were post-menopausal women with osteoporosis. We assessed osteoporosis knowledge, decisional conflict, self-efficacy, and effectiveness in disease management at baseline, immediately post-intervention, and at 3 and 6 months. Linear regression models were used to explore changes in outcomes at 6 months with respect to baseline characteristics.

RESULTS

Two hundred and twenty-five women were randomized, 111 to receive the multimedia tool in addition to the booklet and 114 to receive the booklet alone. Knowledge and decisional conflict scores significantly improved in both groups at all post-intervention assessment points, but with no significant differences in score changes between the groups. Self-efficacy and disease management effectiveness showed no significant changes from baseline. In the entire cohort, younger age was associated with better effectiveness in disease management and Hispanic women had greater gains in knowledge at 6 months compared to White women. Women with limited health literacy who had received the multimedia tool in addition to the printed materials had higher decisional conflict than those who received printed materials alone.

CONCLUSION

Both multimedia and printed tools increased knowledge and decreased decisional conflict to the same extent, neither of the educational materials proved to be better than the other. For women with limited health literacy, receiving the booklet alone was more effective in reducing decisional conflict after 6 months, than adding the multimedia tool.

Molecular Mechanisms Mediating Adaptation to Exercise

Several experimental and human studies documented the preventive and therapeutic effects of exercise on the normal physiological function of different body systems during aging as well as various diseases. Recent studies using cellular and molecular (biochemical, proteomics, and genomics) techniques indicated that exercise modifies intracellular and extracellular signaling and pathways. In addition, in vivo or in vitro experiments, particularly, using knockout and transgenic animals, helped to mimic physiological conditions during and after exercise. According to the findings of these studies, some important signaling pathways modulated by exercise are Ca2+-dependent calcineurin/activated nuclear factor of activated T-cells, mammalian target of rapamycin, myostatin/Smad, and AMP-activated protein kinase regulation of peroxisome proliferator-activated receptor-gamma coactivator 1-alpha. Such modulations contribute to cell adaptation and remodeling of muscle fiber type in response to exercise. Despite great improvement in this field, there are still several unanswered questions as well as unfixed issues concerning clinical trials' biases and limitations. Nevertheless, designing multicenter standard clinical trials while considering individual variability and the exercise modality and duration will improve the perspective we have on the mechanisms mediating adaptation to exercise and final outcomes.

Management of Primary Ovarian Insufficiency Symptoms in Survivors of Childhood and Adolescent Cancer

Cancer treatments can damage the ovaries, causing primary ovarian insufficiency (POI), a condition associated with numerous sequelae that impact long-term quality of life. This article systematically reviews the literature on the prevalence, surveillance, and treatment of POI in survivors of pediatric and adolescent and young adult (AYA) cancers. A systematic review of the literature was conducted in January 2018 through a search of Medline, Embase, Web of Science, and SCOPUS, alongside the screening of relevant reference lists. An initial search identified 746 potentially relevant studies. A total of 36 studies were included in the final review. Studies were categorized into one of the following categories: incidence/prevalence of POI, measurement of ovarian reserve, and other. Depending on patient characteristics, cancer diagnosis, and treatment, the prevalence of POI ranged from 2.1% to 82.2%. Risk factors for POI included exposure to alkylating agents and abdominal/pelvic radiation. POI may be associated with a number of complications, including low bone mineral density and poor cardiovascular health. Radiotherapy and chemotherapy are known to cause gonadal damage in female survivors of pediatric and AYA cancers. Acute or chronic effects depend on the dose of treatment, age of the individual, radiotherapy field, and ovarian reserve of the individual. Some women experience short-term loss of reproductive function and then may resume menstrual cycles, months or even years later. Although protecting fertility through banking of mature eggs, embryos, and tissue samples has become standard of care, additional steps need to be taken to ensure that patients have adequate hormone levels to maintain whole-body health, including life expectancy, bone health, cardiovascular health, quality of life, sexual and genitourinary function, and neurologic function. Surveillance and management of each of these comorbidities is critically important to survivor health.

Disparities in osteoporosis by race/ethnicity, education, work status, immigrant status, and economic status in the United States

AIMS

Osteoporosis is one of the most common bone health diseases affecting older adults in US. Addressing disparities in osteoporosis will help to enhance the quality of bone care in the nation's bone health programs.

MATERIALS & METHODS

We used the data of adult participants of the National Health and Nutrition Examination Survey with reported bone mineral density measured during the periods of 2005-2010 and 2013-2014 to examine disparities in osteoporosis based on race/ethnicity, educational attainment, work status, immigrant status, and economic status in US.

RESULTS

Based on educational attainment, the age- and sex-standardized osteoporosis prevalence (SOP) was highest among those with less than a high school education (HSE) (5.1%, 95% CI (CI): 4.3%-5.9%), whereas it was lowest among those with more than HSE (3.2%, CI: 2.7%-3.6%). Based on work status, SOP was highest among unemployed participants (5.4%, CI: 1.9%-8.9%), whereas it was lowest among working participants (2%, CI: 1.6%-2.4%). Based on immigrant status, SOP was highest among non-citizens (6.4%, CI: 5%-7.8%), whereas it was lowest among those born in US (3.4%, CI: 3.1%-3.7%). Based on economic status, SOP was highest among those with poverty-to-income ratio (PIR) <1 (5.5%, CI: 4.4%-6.5%), whereas it was lowest among those with PIR ≥ 4 (2.4%, CI: 1.9%-2.9%).

CONCLUSIONS

Osteoporosis was more prevalent among US adults who were non-citizens, less educated, unemployed, and had lower income. The observed disparities suggest a need for interventions to promote better quality bone care among the socioeconomically disadvantaged groups.

Transient osteoporosis of the hip after bariatric surgery

Transient osteoporosis is a rare manifestation of acute hip pain which typically resolves with weight-bearing restrictions and pain management. Our case report presents a patient who experienced atraumatic right hip pain a few weeks after an uncomplicated bariatric surgery and was diagnosed with transient osteoporosis of the hip. Her condition resolved after weeks of protected weight-bearing restrictions and nonsteroidal anti-inflammatories. Transient osteoporosis should be considered in the differential diagnosis of hip pain in patients who have undergone previous bariatric surgery.

Mechanisms of Action of Dehydroepiandrosterone

Dehydroepiandrosterone (3β-hydroxy-5-androsten-17-one, DHEA) and its sulfated metabolite DHEA-S are the most abundant steroids in circulation and decline with age. Rodent studies have shown that DHEA has a wide variety of effects on liver, kidney, adipose, reproductive tissues, and central nervous system/neuronal function. The mechanisms by which DHEA and DHEA-S impart their physiological effects may be direct actions on plasma membrane receptors, including a DHEA-specific, G-protein-coupled receptor in endothelial cells; various neuroreceptors, e.g., aminobutyric-acid-type A, N-methyl-d-aspartate (NMDA), and sigma-1 (S1R) receptors; by binding steroid receptors: androgen and estrogen receptors (ARs, ERα, or ERβ); or by their metabolism to more potent sex steroid hormones, e.g., testosterone, dihydrotestosterone, and estradiol, which bind with higher affinity to ARs and ERs. DHEA inhibits voltage-gated T-type calcium channels. DHEA activates peroxisome proliferator-activated receptor (PPARα) and CAR by a mechanism apparently involving PP2A, a protein phosphatase dephosphorylating PPARα and CAR to activate their transcriptional activity. We review our recent study showing DHEA activated GPER1 (G-protein-coupled estrogen receptor 1) in HepG2 cells to stimulate miR-21 transcription. This chapter reviews some of the physiological, biochemical, and molecular mechanisms of DHEA and DHEA-S activity.

Soy-Based Foods Are Negatively Associated with Cognitive Decline in Taiwan's Elderly

Cognitive impairment is a common neurodegenerative disease in the elderly. Dietary factors have an important role in cognitive dysfunction. Soy has many benefits, and consumption of soy-based foods is general in East Asian countries. In this study, we want to investigate the association between cognitive function decline and soy-based food intake among the elderly in Taiwan. This cross-sectional study was based on data obtained from the 2005-2008 Nutrition and Health Survey in Taiwan (NAHSIT). Subjects aged less than 65 y or with missing data were excluded. There was a total of 1,105 participants aged 65 and over who completed Short Portable Mental Status Questionnaire (SPMSQ). Eighty-five-point-six percent of participants consumed soy-based foods every day. After adjustment for potential variables, the logistic regression model showed significant associations for age, gender, education, soy-based foods intake and physical component summary (PCS). Age and female gender were both positively correlated with cognitive impairment (odds ratios: 1.1 and 4.43, respectively). Furthermore, there were negative correlations for education, soy-based foods intake and PCS (odds ratios: 0.25, 0.45 and 0.97, respectively). In this study, we found that soy-based foods were negatively associated with cognitive function decline among Taiwanese elderly. This result may be used as a reference for dietary advice for the elderly.

Clinical guidelines for the prevention and treatment of osteoporosis: summary statements and recommendations from the Italian Society for Orthopaedics and Traumatology

BACKGROUND

The Italian Society for Orthopaedics and Traumatology conceived this guidance-which is primarily addressed to Italian orthopedic surgeons, but should also prove useful to other bone specialists and to general practitioners-in order to improve the diagnosis, prevention, and treatment of osteoporosis and its consequences.

MATERIALS AND METHODS

Literature reviews by a multidisciplinary team.

RESULTS

The following topics are covered: the role of instrumental, metabolic, and genetic evaluations in the diagnosis of osteoporosis; appraisal of the risk of fracture and thresholds for intervention; general strategies for the prevention and treatment of osteoporosis (primary and secondary prevention); the pharmacologic treatment of osteoporosis; the setting and implementation of fracture liaison services for tertiary prevention. Grade A, B, and C recommendations are provided based on the main levels of evidence (1-3). Toolboxes for everyday clinical practice are provided.

CONCLUSIONS

The first up-to-date Italian guidelines for the primary, secondary, and tertiary prevention of osteoporosis and osteoporotic fractures are presented.

The effects of different intensities of exercise and active vitamin D on mouse bone mass and bone strength

Physical exercise is beneficial to bone health. However, little is known how different intensities of exercise affect bone mass and strength. In the present study, we used young mice to study the effects of different intensities of exercise on bone mass and bone strength in comparison to pharmacological doses of active vitamin D (calcitriol). We found that only the medium level of exercise tested showed a positive effect on bone mineral density, trabecular bone volume, and bone strength, which are attributable to a decrease in bone resorption and an increase in bone formation, with the latter being accompanied by an increase in the number of osteogenic mesenchymal stem cells in the bone marrow. Calcitriol increases bone volume and bone strength, yet the combination of calcitriol and medium-intensity exercise did not further improve bone mass or strength. Moreover, calcitriol also showed some protective effect on the bone in mice with high levels of exercise. These results indicate that exercise at medium intensity increases bone mass and strength via affecting both bone formation and resorption and that its beneficial effects on bone mass cannot be further improved by calcitriol.

Serum Preadipocyte Factor 1 Levels Are Not Associated with Bone Mineral Density among Healthy Postmenopausal Korean Women

BACKGROUND

Multipotent mesenchymal stem cells can differentiate into adipocytes or osteoblasts through closely regulated lineage-control processes. However, adipocyte precursor cells release preadipocyte factor 1 (Pref-1), which inhibits the differentiation of mesenchymal stem cells into mature adipocytes and osteoblasts. Previous studies have also reported an inverse association between Pref-1 levels and bone mineral density (BMD) among patients with anorexia nervosa.

METHODS

In this retrospective study, we examined the correlations between Pref-1 levels and BMD among 124 healthy postmenopausal women (>50 years old). The patients had provided information regarding their clinical characteristics, and underwent blood testing and serum Pref-1 testing.

RESULTS

The subjects' mean age was 59.9±7.1 years and the median time since menopause onset was 9.1 years. A history of osteoporotic fracture was identified in 23 subjects (19%). Serum Pref-1 levels were not significantly correlated with BMD values at the lumbar spine (R²=0.038, P=0.109), femur neck (R²=0.017, P=0.869), and total hip (R²=0.041, P=0.09), and multivariate analyses with adjustment for age and body mass index also did not detect any significant correlations. Subgroup analyses according to a history of fracture also did not detect significant associations between Pref-1 levels and BMD values.

CONCLUSION

In our study population, it does not appear that serum Pref-1 levels are significantly associated with BMD values and osteoporosis.

Effects of exercise on adolescent and adult hypothalamic and hippocampal neuroinflammation

Adolescence is a period of significant brain plasticity that can be affected by environmental factors, including the degree of physical activity. Here we hypothesized that adolescent rats would be more sensitive to the beneficial metabolic and anti-inflammatory effects of voluntary exercise than adult rats, whose more mature brains have less capacity for plasticity. We tested this by giving adolescent and adult Wistar rats four weeks' voluntary access to running wheels. At the end of this period we assessed metabolic effects, including weight and circulating leptin and ghrelin, as well as performance in a novel object recognition test of memory and central changes in neuronal proliferation, survival, synaptic density, and inflammatory markers in hippocampus. We found exercise reduced fat mass and circulating leptin levels in both adults and adolescents but suppressed total weight gain and lean mass in adults only. Exercise stimulated neuronal proliferation in the suprapyramidal blade of the dentate gyrus in both adults and adolescents without altering the number of mature neurons during this time frame. Exercise also increased dentate microglial numbers in adolescents alone and microglial numbers in this region were inversely correlated with performance in the novel object recognition test. Together these data suggest that adolescent hippocampal microglia are more sensitive to the effects of exercise than those of adults, but this leads to no apparent improvement in recognition memory. © 2016 Wiley Periodicals, Inc.

Understanding the Cellular and Molecular Mechanisms of Physical Activity-Induced Health Benefits

The beneficial effects of physical activity (PA) are well documented, yet the mechanisms by which PA prevents disease and improves health outcomes are poorly understood. To identify major gaps in knowledge and potential strategies for catalyzing progress in the field, the NIH convened a workshop in late October 2014 entitled "Understanding the Cellular and Molecular Mechanisms of Physical Activity-Induced Health Benefits." Presentations and discussions emphasized the challenges imposed by the integrative and intermittent nature of PA, the tremendous discovery potential of applying "-omics" technologies to understand interorgan crosstalk and biological networking systems during PA, and the need to establish an infrastructure of clinical trial sites with sufficient expertise to incorporate mechanistic outcome measures into adequately sized human PA trials. Identification of the mechanisms that underlie the link between PA and improved health holds extraordinary promise for discovery of novel therapeutic targets and development of personalized exercise medicine.

Genetics of androgen metabolism in women with infertility and hypoandrogenism

Hypoandrogenism in women with low functional ovarian reserve (LFOR, defined as an abnormally low number of small growing follicles) adversely affects fertility. The androgen precursor dehydroepiandrosterone (DHEA) is increasingly used to supplement treatment protocols in women with LFOR undergoing in vitro fertilization. Due to differences in androgen metabolism, however, responses to DHEA supplementation vary between patients. In addition to overall declines in steroidogenic capacity with advancing age, genetic factors, which result in altered expression or enzymatic function of key steroidogenic proteins or their upstream regulators, might further exacerbate variations in the conversion of DHEA to testosterone. In this Review, we discuss in vitro studies and animal models of polymorphisms and gene mutations that affect the conversion of DHEA to testosterone and attempt to elucidate how these variations affect female hormone profiles. We also discuss treatment options that modulate levels of testosterone by targeting the expression of steroidogenic genes. Common variants in genes encoding DHEA sulphotransferase, aromatase, steroid 5α-reductase, androgen receptor, sex-hormone binding globulin, fragile X mental retardation protein and breast cancer type 1 susceptibility protein have been implicated in androgen metabolism and, therefore, can affect levels of androgens in women. Short of screening for all potential genetic variants, hormonal assessments of patients with low testosterone levels after DHEA supplementation facilitate identification of underlying genetic defects. The genetic predisposition of patients can then be used to design individualized fertility treatments.

Dioxin Exposure Impairs BMP-2-Mediated Spinal Fusion in a Rat Arthrodesis Model

BACKGROUND

Cigarette smoking inhibits bone-healing and leads to increased rates of pseudarthrosis. However, the mechanisms behind these effects are controversial. Dioxin (2,3,7,8-tetrachlorodibenzo-p-dioxin)--a cigarette smoke constituent and potent activator of the aryl hydrocarbon receptor (Ahr)--negatively impacts bone quality and osteoblast differentiation. We hypothesized that activation of the Ahr by dioxin would inhibit bone morphogenetic protein (BMP)-2-mediated spinal fusion in a rat arthrodesis model.

METHODS

Female Long-Evans rats were pretreated with dioxin or vehicle in six weekly doses, followed by bilateral posterior lumbar spinal fusion across the L4-L5 transverse processes using recombinant human BMP (rhBMP)-2. Treatments continued until sacrifice at four weeks postoperatively. A third group was treated with dioxin for six weeks, followed by a recovery period of four elimination half-lives to assess the reversible effects of dioxin exposure on spinal fusion capacity. Bone formation and fusion capacity were evaluated using fusion scoring, radiography, micro-computed tomography, and histologic analysis.

RESULTS

Fusion scores for dioxin-treated and dioxin-recovery rats were significantly lower than those for controls. Although fusion rates were also significantly reduced in dioxin-treated animals relative to controls (50% versus 100%, respectively), rates were not significantly reduced in dioxin-recovery animals (80%).

CONCLUSIONS

Dioxin treatment significantly inhibited spinal fusion in a rat arthrodesis model, and a prolonged cessation of dioxin exposure facilitated only a partial recovery of bone-healing capacity. This finding indicates that, although the effects of dioxin are persistent, an extended recovery from exposure could potentially restore bone regeneration in vivo.

CLINICAL RELEVANCE

Development of a pharmacologic agent that reduces the adverse effects of cigarette smoke on bone-healing could prove useful to orthopaedic surgeons. Since dioxin and other similar cigarette smoke toxins exert their effects through Ahr pathway activation, the receptor represents a potential therapeutic target to improve spinal fusion rates in patients who smoke.

Developing a Tailored Smoking Cessation Intervention for Rheumatoid Arthritis Patients

PURPOSE

Smoking is associated with an increased risk of comorbidities in rheumatoid arthritis (RA) and may reduce the efficacy of anti-rheumatic therapies. Smoking cessation is therefore an important goal in RA. Our previous qualitative research identified five RA-related barriers to smoking cessation: lack of support; limited knowledge of the relationship between smoking and RA; uncontrolled pain; inability to exercise; and using smoking as a coping strategy. The aim of this article is to describe the process of developing a smoking cessation intervention for RA patients based on these themes.

METHODS

A comprehensive review of the literature on smoking cessation was undertaken. A tailored smoking cessation programme was designed to address each RA-specific barrier. A meeting was convened with key staff of Arthritis New Zealand to develop a consensus on feasible design to deliver a smoking cessation programme based on existing best practice and smoking cessation resources, and tailored within existing Arthritis New Zealand service delivery frameworks.

RESULTS

A three-month intervention was designed to be delivered by trained arthritis educators, with the following key components: nicotine replacement therapy for eight weeks; a telephone or face-to-face interview with each patient to determine their individual specific RA-related barriers to smoking cessation; and individualized education and support activities which addressed these barriers. The intervention also included three follow-up telephone calls; a support website; and 12 weekly smoking cessation advice emails.

CONCLUSIONS

A RA-specific smoking cessation invention was developed, matching support to specific issues within each patient's experience. A pilot study is in progress to evaluate the programme's efficacy. Copyright © 2015 John Wiley & Sons, Ltd.

Primary biliary cirrhosis: Pathophysiology, clinical presentation and therapy

Primary biliary cirrhosis (PBC) is an autoimmune, slowly progressive, cholestatic, liver disease characterized by a triad of chronic cholestasis, circulating anti-mitochondrial antibodies (AMA), and characteristic liver biopsy findings of nonsuppurative destructive cholangitis and interlobular bile duct destruction. About 10% of PBC patients, however, lack AMA. A variant, called PBC-autoimmune hepatitis (AIH) overlap, is characterized by the above findings of PBC together with findings of elevated serum alanine aminotransferase, elevated serum immunoglobulin G, and circulating anti-smooth muscle antibodies, with liver biopsy demonstrating periportal or periseptal, lymphocytic, piecemeal necrosis. PBC is hypothesized to be related to environmental exposure in genetically vulnerable individuals. It typically occurs in middle-aged females. Prominent clinical features include fatigue, pruritis, jaundice, xanthomas, osteoporosis, and dyslipidemia. The Mayo Risk score is the most widely used and best prognostic system. Ursodeoxycholic acid is the primary therapy. It works partly by reducing the concentration and injury from relatively toxic bile acids. PBC-AIH overlap syndrome is treated with ursodeoxycholic acid and corticosteroids, especially budesonide. Obeticholic acid and fibrate are promising new, but incompletely tested, therapies. Liver transplantation is the definitive therapy for advanced disease, with about 70% 10-year survival after transplantation. Management of pruritis includes local skin care, dermatologist referral, avoiding potential pruritogens, cholestyramine, and possibly opioid antagonists, sertraline, or rifaximin. Management of osteoporosis includes life-style modifications, administration of calcium and vitamin D, and alendronate. Statins are relatively safe to treat the osteopenia associated with PBC. Associated Sjogren’s syndrome is treated by artificial tears, cyclosporine ophthalmic emulsion to stimulate tear production; and saliva substitutes, cholinergic agents, and scrupulous oral and dental care. Complications of cirrhosis from advanced PBC include esophageal varices, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatoma formation.

A service development study of the assessment and management of fracture risk in Parkinson's disease

Parkinson's disease (PD) is associated with an increased risk of fragility fracture. FRAX and Qfracture are risk calculators that estimate the 10-year risk of hip and major fractures and guide definitive investigation for osteoporosis using dual X-ray absorptiometry (DEXA) imaging. It is unclear which PD patients should be considered for fracture risk assessment and whether FRAX or Qfracture should be used. Seventy-seven patients with PD were recruited in the movement disorders clinic. Data were collected on PD-related characteristics and fracture risk scores were calculated. Patients with previous osteoporotic fractures had a higher incidence of falls (p = 0.0026) and use of bilateral walking aids (p = 0.0187) in addition to longer disease duration (p = 0.0037). Selecting patients with falls in combination with either disease duration >5 years, bilateral walking aids, or previous osteoporotic fracture distinguished patients with and without previous osteoporotic fracture with specificity 67.7 % (95 % CI 55.0-78.8) and sensitivity 100.0 % (95 % CI 73.5-100.0). Qfracture calculated significantly higher fracture risk scores than FRAX for hip (p < 0.0001) and major (p = 0.0008) fracture in PD patients. Receiver operating characteristic curves demonstrated that FRAX outperformed Qfracture with an area under the curve of 0.84 (95 % CI 0.70-0.97, p = 0.0004) for FRAX and 0.68 (95 % CI 52-86, p = 0.0476) for Qfracture major fracture risk calculators. We suggest that falls in combination with either a disease duration longer than 5 years or bilateral walking aids or previous osteoporotic fracture should be used as red flags in PD patients to prompt clinicians to perform a FRAX fracture risk assessment in the neurology clinic.

Orthopedic surgery and its complication in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a multi-systemic immune-complex mediated autoimmune condition which chiefly affects women during their prime year. While the management of the condition falls into the specialty of internal medicine, patients with SLE often present with signs and symptoms pertaining to the territory of orthopedic surgery such as tendon rupture, carpal tunnel syndrome, osteonecrosis, osteoporotic fracture and infection including septic arthritis, osteomyelitis and spondylodiscitis. While these orthopedic-related conditions are often debilitating in patients with SLE which necessitate management by orthopedic specialists, a high index of suspicion is necessary in diagnosing these conditions early because lupus patients with potentially severe orthopedic conditions such as osteomyelitis frequently present with mild symptoms and subtle signs such as low grade fever, mild hip pain and back tenderness. Additionally, even if these orthopedic conditions can be recognized, complications as a result of surgical procedures are indeed not uncommon. SLE per se and its various associated pharmacological treatments may pose lupus patients to certain surgical risks if they are not properly attended to and managed prior to, during and after surgery. Concerted effort of management and effective communication among orthopedic specialists and rheumatologists play an integral part in enhancing favorable outcome and reduction in postoperative complications for patients with SLE through thorough pre-operative evaluation, careful peri-operative monitoring and treatment, as well as judicious postoperative care.