Osteoporosis: the emperor has no clothes

Osteoporosis in 2022: Care gaps to screening and personalised medicine

Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment, and a range of effective pharmacological agents. However, it is apparent that both in the context of primary and secondary fracture prevention, there is a considerable gap between the population at high fracture risk and those actually receiving appropriate antiosteoporosis treatment. In this narrative review article, we document recent work describing the burden of disease, approaches to management, and service provision across Europe, emerging data on gaps in care, and existing/new ways in which these gaps may be addressed at the level of healthcare systems and policy. We conclude that although the field has come a long way in recent decades, there is still a long way to go, and a concerted, integrated effort is now required from all of us involved in this field to address these urgent issues to ensure the best possible outcomes for our patients.

Mast Cell Chymase Has a Negative Impact on Human Osteoblasts

Mast cells have been linked to osteoporosis and bone fractures, and in a previous study we found that mice lacking a major mast cell protease, chymase, develop increased diaphyseal bone mass. These findings introduce the possibility that mast cell chymase can regulate bone formation, but the underlying mechanism(s) has not previously been investigated. Here we hypothesized that chymase might exert such effects through a direct negative impact on osteoblasts, i.e., the main bone-building cells. Indeed, we show that chymase has a distinct impact on human primary osteoblasts. Firstly, chymase was shown to have pronounced effects on the morphological features of osteoblasts, including extensive cell contraction and actin reorganization. Chymase also caused a profound reduction in the output of collagen from the osteoblasts, and was shown to degrade osteoblast-secreted fibronectin and to activate pro-matrix metallopeptidase-2 released by the osteoblasts. Further, chymase was shown to have a preferential impact on the gene expression, protein output and phosphorylation status of TGFβ-associated signaling molecules. A transcriptomic analysis was conducted and revealed a significant effect of chymase on several genes of importance for bone metabolism, including a reduction in the expression of osteoprotegerin, which was confirmed at the protein level. Finally, we show that chymase interacts with human osteoblasts and is taken up by the cells. Altogether, the present findings provide a functional link between mast cell chymase and osteoblast function, and can form the basis for a further evaluation of chymase as a potential target for intervention in metabolic bone diseases.

Femur geometry and body composition influence femoral neck stresses: A combined fall simulation and beam modelling approach

Metrics of femur geometry and body composition have been linked to clinical hip fracture risk. Mechanistic explanations for these relationships have generally focused on femur strength; however, impact loading also modulates fracture risk. We evaluated the potential effects of femur geometry and body composition on femoral neck stresses during lateral impacts. Fifteen female volunteers completed low-energy sideways falls on to the hip. Additionally, participants completed ultrasound and dual-energy x-ray absorptiometry imaging to characterize trochanteric soft tissue thickness (TSTT) over the hip and six metrics of femur geometry, respectively. Subject-specific beam models were developed and utilized to calculate peak femoral neck stress (σ_Neck), utilizing experimental impact dynamics. Except for femoral neck axis length, all metrics of femur geometry were positively correlated with σ_Neck (all p < 0.05). Larger/more prominent proximal femurs were associated with increased force over the proximal femur, whereas a wider neck-shaft angle was associated with greater stress generation independent of force (all p < 0.05). Body mass index (BMI) and TSTT were negatively correlated with σ_Neck (both p < 0.05). Despite strong correlations, these metrics of body composition appear to influence femoral neck stresses through different mechanisms. Increased TSTT was associated with reduced force over the proximal femur, whereas increased BMI was associated with greater resistance to stress generation (both p < 0.05). This study provided novel insights into the mechanistic pathways through which femur geometry and body composition may modulate hip fracture risk. Our findings complement clinical findings and provide one possible explanation for incongruities in the clinical fracture risk and femur strength literature.

Performance of the Fracture Risk Assessment Tool Associated with Muscle Mass Measurements and Handgrip to Screen for the Risk of Osteoporosis in Young Postmenopausal Women

OBJECTIVE

 To evaluate the improvement in screening accuracy of the Fracture Risk Assessment Tool (FRAX) for the risk of developing osteoporosis among young postmenopausal women by associating with it clinical muscle mass measures.

METHODS

 A sample of postmenopausal women was submitted to calcaneal quantitative ultrasound (QUS), application of the FRAX questionnaire, and screening for the risk of developing sarcopenia at a health fair held in the city of São Bernardo do Campo in 2019. The sample also underwent anthropometric measurements, muscle mass, walking speed and handgrip tests. A major osteoporotic fracture (MOF) risk ≥ 8.5% on the FRAX, a classification of medium risk on the clinical guideline of the National Osteoporosis Guideline Group (NOGG), and a QUS T-score ≤ -1.8 sd were considered risks of having low bone mass, and QUS T-score ≤ -2.5sd, risk of having fractures.

RESULTS

 In total, 198 women were evaluated, with a median age of 64 ±  7.7 years, median body mass index (BMI) of 27.3 ±  5.3 kg/m² and median QUS T-score of -1.3 ±  1.3 sd. The accuracy of the FRAX with a MOF risk ≥ 8.5% to identify women with T-scores ≤ -1.8 sd was poor, with an area under the curve (AUC) of 0.604 (95% confidence interval [95%CI]: 0.509-0.694) for women under 65 years of age, and of 0.642 (95%CI: 0.571-0.709) when age was not considered. Including data on muscle mass in the statistical analysis led to a significant improvement for the group of women under 65 years of age, with an AUC of 0,705 (95%CI: 0.612-0.786). The ability of the high-risk NOGG tool to identify T-scores ≤ -1.8 sd was limited.

CONCLUSION

 Clinical muscle mass measurements increased the accuracy of the FRAX to screen for osteoporosis in women aged under 65 years.

Efficacy of Antiresorptive Treatment in Osteoporotic Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

OBJECTIVES

To investigate concerns surrounding the benefits of antiresorptive drugs in older adults, a systematic review was carried out to evaluate the efficacy of these treatments in the prevention of osteoporotic hip fractures in older adults.

DESIGN

a systematic review and meta-analysis of randomized clinical trials.

SETTING AND PARTICIPANTS

older adults ≥65 years with osteoporosis, with or without a previous fragility fracture. Studies with cancer-related and corticosteroid-induced osteoporosis, participants <65 years and no reported hip fracture were not included.

METHODS

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ISI Web of Science and Scopus databases were searched. The primary outcome was hip fracture, and subgroup analysis (≥75 years, with different drug types and secondary prevention) and sensitivity analysis was carried out using a GRADE evaluation. Secondary outcomes were any type of fractures, vertebral fracture, bone markers and adverse events. The risk of bias was assessment with the Cochrane risk of bias tool.

RESULTS

A total of 12 randomised controlled trials (RCTs) qualified for this meta-analysis, with 36,196 participants. Antiresorptive drugs have a statistically significant effect on the prevention of hip fracture (RR=0.70; 95%CI 0.60 to 0.81), but with a moderate GRADE quality of evidence and a high number needed to treat (NNT) of 186. For other outcomes, there is a statistically significant effect, but with a low to moderate quality of evidence. Antiresorptives showed no reduction in the risk of hip fracture in people ≥75 years. The results for different drug types, secondary prevention and sensitivity analysis are similar to the main analyses and have the same concerns.

CONCLUSIONS

Antiresorptive drugs have a statistically significant effect on preventing hip fracture but with a moderate quality (unclear/high risk of bias) and high NNT (186). This small benefit disappears in those ≥75 years, but increases in secondary prevention. More RCTs in very old osteoporotic adults are needed.

How do people understand overtesting and overdiagnosis? Systematic review and meta-synthesis of qualitative research

RATIONALE

The public should be informed about overtesting and overdiagnosis. Diverse qualitative studies have examined public understandings of this information. A synthesis was needed to systematise the body of evidence and yield new, generalisable insights.

AIM

Synthesise data from qualitative studies exploring patient and public understanding of overtesting and overdiagnosis.

METHODS

We searched Scopus, CINAHL, Ovid MEDLINE and PsycINFO databases from inception to March 18, 2020. We included published English-language primary studies exploring the perspectives of patients/the public about overtesting/overdiagnosis from any setting, year and relating to any condition. Only qualitative parts of mixed-methods studies were synthesised. We excluded studies that only examined overtreatment or sampled people with specialised medical knowledge. Two authors independently selected studies, extracted data, assessed the methodological quality of included studies using the CASP tool, and assessed confidence in the synthesis findings using the GRADE-CERQual approach. Data was analysed using thematic meta-synthesis, utilising descriptive and interpretive methods.

RESULTS

We synthesised data from 21 studies, comprising 1638 participants, from 2754 unique records identified. We identified six descriptive themes, all graded as moderate confidence (indicating they are likely to reasonably represent the available evidence): i) high confidence in screening and testing; ii) difficulty in understanding overuse; iii) acceptance that overuse can be harmful; iv) rejection or problematisation of overuse; v) limited impacts of overuse information on intended test and screening uptake; vi) desire for information and shared decision-making regarding overuse. The descriptive themes were underpinned by two analytic themes: i) perceived intrinsic value of information and information gathering, and; ii) differences in comprehension and acceptance of overuse concepts.

CONCLUSIONS

This study identified novel and important insights about how lay people interpret overuse concepts. It will guide the development of more effective public messages about overuse, highlighting the importance of interpretative frameworks in these communications.

Prior loss of body mass index, low body mass index, and central obesity independently contribute to higher rates of fractures in elderly women and men

We aimed to comprehensively evaluate the association of body composition with fracture risk using longitudinal data from a Swedish cohort of 44,366 women and men (mean age of 70 years) and a subcohort of 5022 women. We estimated hazard ratios (HRs) of fracture for baseline body mass index (BMI), BMI change during the prior 12 and 18 years, baseline waist-to-height ratio, total and regional distribution of fat and lean mass, with and without areal bone mineral density (BMD) adjustment. During follow-up (median 8.7 years), 7290 individuals sustained a fracture, including 4279 fragility fractures, of which 1813 were hip fractures. Higher baseline BMI and prior gain in BMI were inversely associated with all types of fracture. Lower fracture rate with higher baseline BMI was seen within every category of prior BMI change, whereas higher prior BMI gain conferred a lower rate of fracture within those with normal baseline BMI. Each standard deviation (SD) higher baseline waist-to-height ratio, after adjustment for BMI, was associated with higher rates of hip fracture in both women and men (HR 1.12; 95% CI, 1.05-1.19). In the subcohort (median follow-up 10 years), higher baseline fat mass index (FMI) and appendicular lean mass index (LMI) showed fracture-protective effects. After BMD adjustment, higher baseline BMI, total LMI, FMI, and higher prior BMI gain were associated with higher fracture rate. Baseline fat distribution also was associated with fracture rate; a 1-SD higher android to gynoid fat mass ratio in prior BMI gainers was associated with BMD-adjusted HRs of 1.16 (95% CI, 1.05-1.28) for any fracture and 1.48 (95% CI, 1.16-1.89) for hip fracture. This pattern was not observed among prior BMI losers. These findings indicate that for optimal fracture prevention, low baseline BMI, prior BMI loss and high baseline central obesity should be avoided in both women and men. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Situational risk factors for fall-related vertebral fractures in older men and women

Situational factors might help explain why most vertebral fractures occur in older people without a previous osteoporosis diagnosis. After adjusting for predisposing risk factors, the activity before the fall, type of fall, and falling direction remained as strong determinants of fall-related vertebral fractures in older men and women.

INTRODUCTION

A matched case-control study was conducted to investigate the effects of situational factors, in addition to predisposing factors, on clinical vertebral fractures in older men and women in Taiwan.

METHODS

Cases were community-dwelling individuals aged ≥ 65 years who visited emergency departments (EDs) of two university-affiliated hospitals due to a fall and had a primary diagnosis of a vertebral fracture during a 1-year period in 2017. Five control patients per case, matched by the time of falling, gender, and age, who sought care in the same ED due to a fall resulting in a soft tissue injury were selected. A total of 64 men (age range: 65 ~ 99 years) and 194 women (age range: 65 ~ 100 years), diagnosed with a vertebral fracture, participated in the study.

RESULTS

Multivariable logistic models were conducted separately for men and women. Results suggested that the following factors were significantly associated with an increased risk of vertebral fractures in men: a low educational level (adjusted odds ratio [OR] = 1.95; 95% confidence interval (CI), 1.02 ~ 3.71), asthma (OR = 2.96; 95% CI, 1.35 ~ 6.92), depression (OR = 4.31; 95% CI, 1.03 ~ 17.5), toileting (OR = 2.30; 95% CI, 1.04 ~ 4.94), slipping (OR = 5.27; 95% CI, 1.80 ~ 15.4), stepping down (OR = 3.99; 95% CI, 1.40 ~ 11.4), sudden leg weakness (OR = 3.73; 95% CI, 1.13 ~ 12.4), and falling backwards (OR = 3.78; 95% CI, 1.83 ~ 7.80); and in women: a fracture history (OR = 2.00; 95% CI, 1.07 ~ 3.76), osteoporosis (OR = 1.94; 95% CI, 1.15 ~ 3.49), getting in/out of the bed/chair (OR = 1.90; 95% CI, 1.07 ~ 3.39), stepping down (OR = 2.10; 95% CI, 1.17 ~ 3.77), and falling backwards (OR = 4.00; 95% CI, 2.39 ~ 6.68) and sideways (OR = 2.61; 95% CI, 1.38 ~ 4.96).

CONCLUSIONS

The combination of predisposing and situational risk factors may display a more comprehensive risk profile for the occurrence of VFs, and thus, interventions that add both types of risk factors may result in greater risk reduction of VFs, although those specifically targeted at situational risk factors during falls are limited and their effectiveness and efficiency remained to be explored.

Variations in situational risk factors for fractures of the distal forearm, hip, and vertebrae in older women

Background

Situational factors during a fall among three common types of fractures of the distal forearm, hip, and vertebrae among older women in Taiwan were investigated.

Methods

In 2016 ~ 2017, study participants were identified from those aged ≥65 years who visited emergency departments due to a fall in two university-affiliated hospitals in Taipei. In addition to individual characteristics, situational factors during the fall (location, activity, change of center of mass, fall mode, fall direction, initiating a protective response, and being hit) were collected. A sample of 203 distal-forearm fractures, 189 vertebral fractures, and 375 hip fractures was recruited, while 717 women with a soft-tissue injury were used as a control group. The identification of situational risk factors for each type of fracture was validated by using those who sustained one of the other two types of fracture as a control group.

Results

After adjusting for age and other individual characteristics, compared to soft-tissue injuries, distal-forearm fractures were significantly more likely to occur with slips (odds ratio [OR] = 11.0; 95% confidence interval [CI] = 4.76 ~ 25.4), trips (OR = 3.40; 95% CI = 1.42 ~ 8.17), step-downs (OR = 4.95; 95% CI = 2.15 ~ 11.4), and from sideways falls (OR = 1.73; 95% CI = 1.12 ~ 2.67) and significantly less likely to occur indoors (OR = 0.62; 95% CI = 0.42 ~ 0.90) or from backwards falls (OR = 0.62; 95% CI = 0.41 ~ 0.95). Hip fractures were significantly more likely to occur with step-downs (OR = 1.76; 95% CI = 1.13 ~ 2.75) and from backwards (OR = 3.16; 95% CI = 2.15 ~ 4.64) or sideways falls (OR = 5.56; 95% CI = 3.67 ~ 8.41) and significantly less likely when hitting an object (OR = 0.26; 95% CI = 0.13 ~ 0.52) or initiating a protective response (OR = 0.58; 95% CI = 0.36 ~ 0.93). Vertebral fractures were significantly more likely to occur with slips (OR = 2.42; 95% CI = 1.30 ~ 4.50), step-downs (OR = 2.53; 95% CI = 1.43 ~ 4.48), and backwards falls (OR = 2.15; 95% CI = 1.39 ~ 3.32). Similar results were found in the validation analyses.

Conclusions

Large variations in situational risk factors for the three types of fracture in older women existed. A combination of individual and situational risk factors may display a more-comprehensive risk profile for the three types of fracture, and an intervention that adds training programs on safe landing strategies and effective compensatory reactions may be valuable in preventing serious injuries due to a fall.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02157-2.

Reduced Risk of Reoperation Using Intramedullary Nailing with Femoral Neck Protection in Low-Energy Femoral Shaft Fractures

BACKGROUND

In Sweden, approximately 1 in 4 women who are ≥50 years of age will sustain a hip fracture. Patients treated for a femoral shaft fracture are likely to have an even higher risk. We hypothesized that intramedullary nails protecting the femoral neck reduce the risk of subsequent hip fracture and allow the patient to avoid a challenging reoperation.

METHODS

Between 2008 and 2010, 5,475 fractures of the femoral shaft, in patients who were ≥55 years of age, were registered in a national registry in Sweden. Of these patients, 897 fulfilled the inclusion criteria. We used radiographs and register data to identify the reasons for and the types of reoperation that occurred between the index surgical procedure and December 31, 2014. The categories of implants were determined through a review of radiographs as intramedullary nails with and without femoral neck protection. Reoperations related to peri-implant fractures (including hip fractures) were analyzed as a subgroup of all major reoperations. Multivariable-adjusted, cause-specific hazard ratios (HRs) were calculated to compare the risk of reoperation between cases with nails with and without femoral neck protection.

RESULTS

Among the 897 patients, a total of 82 reoperations were performed. In 640 patients who were treated with intramedullary nails with femoral neck protection, there were 7 peri-implant fractures (no hip fractures) and 27 major reoperations. Among the 257 patients who were treated with intramedullary nails without femoral neck protection, 14 peri-implant hip fractures and 24 major reoperations were identified. Patients who received nails with femoral neck protection had a lower hazard for any peri-implant fracture (multivariable-adjusted cause-specific HR, 0.19 [95% confidence interval (CI), 0.07 to 0.5]) and major reoperation (multivariable-adjusted cause-specific HR, 0.51 [95% CI, 0.28 to 0.92]).

CONCLUSIONS

Intramedullary nails with femoral neck protection in the treatment of low-energy femoral shaft fractures prevent secondary hip fractures and decrease the overall risk of reoperation for 4 to 6 years postoperatively.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Altered levels of BMD, PRL, BAP and TRACP-5b in male chronic patients with schizophrenia

Bone mineral density (BMD) has been found to decrease in schizophrenia patients. We examined BMD and the levels of prolactin (PRL), bone alkaline phosphatase (BAP) and tartrate resistant acid phosphatase isoform 5b (TRACP-5b) in male chronic schizophrenia patients and compared them with healthy controls in a Chinese Han population, which has not been reported before. Male patients with chronic schizophrenia (SPs; n = 79) and healthy controls (HCs; n  = 56) were recruited. BMD and plasma PRL, BAP and TRACP-5b levels were measured and compared between the two groups. The SPs group was further divided into two subgroups: the elevated PRL group (PRL ≥ 25 ng/ml, EPRL; n  = 38) and the normal PRL group (PRL < 25 ng/ml, NPRL; n = 41) in accordance with PRL levels. The levels of BAP and TRACP-5b were measured using sandwich enzyme-linked immunosorbent assay (ELISA) while serum PRL was measured with an Access Immunoassay Analyzer. BMD was determined by quantitative computed tomography. BMD levels significantly decreased and serum PRL and TRACP-5b levels were significantly higher in male chronic schizophrenia patients. The EPRL group had remarkably lower BMD and BAP level and higher TRACP-5b levels compared with the NPRL group and HCs. Moreover, there was a negative correlation between BMD and TRACP-5b in the EPRL group. We found that BMD, BAP and TRACP-5b levels in the EPRL group were significantly different than HCs and the NPRL group. PRL levels in schizophrenia patients may be related to BMD and bone metabolism. Monitoring BMD and markers of bone metabolism in clinical practice may therefore be helpful to understand the bone health status of schizophrenia patients.

Time to benefit and the long-term persistence of new users of oral bisphosphonates

INTRODUCTION

This study aimed to examine long-term persistence in new users of oral bisphosphonates in a population-wide cohort in Manitoba, Canada.

MATERIALS AND METHODS

A longitudinal observational study was conducted using administrative health data characterizing long-term bisphosphonate persistence in those who started treatment between 1997 and 2018. Treatment discontinuation was evaluated using Kaplan-Meier methods. Cox regression was used to examine associations between discontinuation and osteoporosis diagnosis, previous fractures, and age. A sub-analysis of users with FRAX scores examined the relationship between 10-year fracture risk estimations and discontinuation.

RESULTS

Of 42,249 new bisphosphonate users, median age was 71 years, with 88.6% being female. Median duration of bisphosphonate use was 0.95 years (IQR 0.25, 3.9 years). Overall, 47.9% of incident users persisted up to 1 year, 25.0% persisted up to 3 years, and 14.1% up to 5 years. Presence of an indication for bisphosphonate use was associated with decreased discontinuation risk. Persistence generally increased with age. Having a BMD test performed was a predictor of lower discontinuation. The strongest predictor was having an osteoporosis diagnosis [HR for discontinuation = 0.68 (95% CI 0.66, 0.70)]. In users with FRAX scores (n = 14,114), moderate-risk [HR = 0.86 (95% CI 0.77, 0.96)] and high-risk users [HR = 0.77 (95% CI 0.69, 0.85)] were less likely to discontinue compared to lower-risk users.

CONCLUSIONS

A rapid decline in bisphosphonate persistence was shown. Almost half of users would not be expected to achieve clinically relevant benefits with a persistence of less than 1 year. Allowing informed choice in high-risk patients may be the best way to focus on those likely to benefit and persist with treatment.

General and Specific Considerations as to why Osteoporosis-Related Care Is Often Suboptimal

PURPOSE OF REVIEW

The assessment of fracture risk and use of antiosteoporosis medications have increased greatly over the last 20-30 years. However, despite this, osteoporosis care remains suboptimal worldwide. Even in patients who have sustained a fragility fracture, fewer than 20% actually receive appropriate antiosteoporosis therapy in the year following the fracture. There is also evidence that treatment rates have declined substantially in the last 5-10 years, in many countries. The goal of this article is to consider the causes for this decline and consider how this situation could be remedied.

RECENT FINDINGS

A number of possible reasons, including the lack of prioritisation of osteoporosis therapy in ageing populations with multimorbidity, disproportionate concerns regarding the rare side effects of anti-resorptives and adverse changes in reimbursement in the USA, have been identified as contributing factors in poor osteoporosis care. Improved secondary prevention strategies; screening measures (primary prevention) and appropriate, cost-effective guideline and treatment threshold development could support the optimisation of osteoporosis care and prevention of future fractures.

In Vivo Assessment of Cortical Bone Fragility

PURPOSE OF REVIEW

This review updates readers on recent developments in the assessment of cortical bone fragility in vivo. The review explains the clinical need that motivated the development of Cortical Bone Mechanics Technology™ (CBMT) as a scientific instrument, its unique capabilities, and its necessary further development as a medical device.

RECENT FINDINGS

Clinical experience with dual-energy X-ray absorptiometry has led to calls for new clinical methods for assessing bone health. CBMT is a noninvasive, dynamic 3-point bending test that makes direct, functional measurements of the mechanical properties of cortical bone in ulnas of living people. Its technical validity in accurate measurements of ulna flexural rigidity and its clinical validity in accurate estimations of quasistatic ulna bending strength have been demonstrated. Because CBMT is a whole bone test, its measurements reflect the influences of bone quantity and bone quality at all hierarchical levels.

Cost-Effectiveness of the Screening for the Primary Prevention of Fragility Hip Fracture in Spain Using FRAX®

To assess the cost-effectiveness of the primary prevention of fragility hip fractures through opportunistic risk-based screening using FRAX^® among women aged 70 to 89 years, and the subsequent treatment with alendronate in women at high-risk, from the Spanish national health system perspective. We performed a discrete-event simulation model. Women were categorized in low, intermediate and high-risk of fragility hip fracture through screening based on the FRAX^® risk assessment tool score (Spanish version). Low-risk women received lifestyle recommendations whereas the high-risk group was assigned to alendronate treatment. For women at intermediate-risk, treatment decision was based on a recalculated score considering bone mineral density (BMD). The cost-effectiveness analysis tested six scenarios defined by different FRAX^® cut-off values assessing the incremental costs per averted fracture in 20 years. Deterministic sensitivity analysis was performed. We included a random sample of 5146 women obtained from a Spanish cohort of women referred for BMD. The most cost-effective intervention had an Incremental Cost-effectiveness Ratio (ICER) of 57,390 € per averted hip fracture and consisted of using the FRAX^® score without BMD and treating women with a score higher than 5%. The ICER exceeded the acceptability threshold of 25,000 € in all the scenarios. Sensitivity analysis based on time to fracture, treatment efficacy, adherence to treatment and cost of dependence resulted in ICERs ranging from 39,216 € to 254,400 €. An ICER of 24,970 € was obtained when alendronate cost was reduced to 1.13 € per month. The use of FRAX^® as screening tool followed by alendronate treatment is not cost-effective in senior women in Spain. Other primary preventions strategies are advisable.

Artificial neural network optimizes self-examination of osteoporosis risk in women

Objective

This study aimed to investigate the application of an artificial neural network (ANN) in optimizing the Osteoporosis Self-Assessment Tool for Asians (OSTA) score.

Methods

OSTA score was calculated for each female participant that underwent dual-energy X-ray absorptiometry examination in two hospitals (one in each of two Chinese cities, Harbin and Ningbo). An ANN model was built using age and weight as input and femoral neck T-score as output. Osteoporosis risk screening by joint application of ANN and OSTA score was evaluated by receiver operating characteristic curve analysis.

Results

Nearly 90% of women with dual-energy X-ray absorptiometry-determined femoral neck osteoporosis were ≥60 years old. The ANN with age and weight as input and OSTA score both identified osteoporosis, with respective accuracy rates of 78.8% and 78.3%. However, both methods failed to identify osteoporosis in women < 60 years old. Compared with OSTA score alone, combined use of the two tools increased the rate of osteoporosis recognition among women > 80 years old.

Conclusions

OSTA score-mediated osteoporosis risk screening should be restricted to women ≥60 years old. Joint application of ANN and OSTA improved osteoporosis risk screening among Chinese women > 80 years old.

A brief history of FRAX

This paper reviews the research programme that went into the development of FRAX® and its impact in the 10 years since its release in 2008.

INTRODUCTION

Osteoporosis is defined on the measurement of bone mineral density though the clinical consequence is fracture. The sensitivity of bone mineral density measurements for fracture prediction is low, leading to the development of FRAX to better calculate the likelihood of fracture and target anti-osteoporosis treatments.

METHODS

The method used in this paper is literature review.

RESULTS

FRAX, developed over an 8-year period, was launched in 2008. Since the launch of FRAX, models have been made available for 64 countries and in 31 languages covering more than 80% of the world population.

CONCLUSION

FRAX provides an advance in fracture risk assessment and a reference technology platform for future improvements in performance characteristics.

How to Proceed in the Disease Concept Debate? A Pragmatic Approach

In the traditional philosophical debate over different conceptual analyses of "disease," it is often presupposed that "disease" is univocally definable and that there are clear boundaries which distinguish this univocal category "disease" from the category of "nondisease." In this paper, I will argue for a shift in the discussion on the concept of "disease" and propose an alternative, pragmatic approach that is based on the conviction that "disease" is not a theoretical concept but a practical term. I develop a view on which our use of the term "disease" is determined by two interacting factors, namely, value-laden considerations about the (un)desirabilty of certain states and discoveries of cause(s) which is/are explanatorily relevant. I show how these factors interact with regard to a taxonomy of kinds of diseases. This pragmatic approach will not lead me to a final definition of "disease," but will result in a more realistic description of the way we build, use, apply, and change our concept of "disease." Meanwhile, it is useful as a basis for critical reflection on disease-labeling in medicine.

Appropriateness of bone density measurement in Switzerland: a cross-sectional study

Background

According to the WHO, osteoporosis is one of the most important non- communicable diseases worldwide. Different screening procedures are controversially discussed, especially concerning the concomitant issues of overdiagnosis and harm caused by inappropriate Dual X-ray Absorptiometry (DXA). The aim of this study was to evaluate the frequency and appropriateness of DXA as screening measure in Switzerland considering individual risk factors and to evaluate covariates independently associated with potentially inappropriate DXA screening.

Methods

Retrospective cross-sectional study using insurance claim data of 2013. Among all patients with DXA screening, women < 65 and men < 70 years without osteoporosis or risk factors for osteoporosis were defined as receiving potentially inappropriate DXA. Statistics included descriptive measures and multivariable regressions to estimate associations of relevant covariates with potentially inappropriate DXA screening.

Results

Of 1,131,092 patients, 552,973 were eligible. Among those 2637 of 10,000 (26.4%) underwent potentially inappropriate DXA screening. Female sex (Odds ratio 6.47, CI 6.41–6.54) and higher age showed the strongest association with any DXA screening.

Female gender (Odds ratio 1.84, CI 1.49–2.26) and an income among the highest 5% (Odds ratio 1.40, CI 1.01–1.98) were significantly positively associated with potentially inappropriate DXA screening, number of chronic conditions (Odds ratio 0.67, CI 0.65–0.70) and living in the central region of Switzerland (Odds ratio 0.67, CI 0.48–0.95) negatively.

Conclusion

One out of four DXAs for screening purpose is potentially inappropriate. Stakeholders of osteoporosis screening campaigns should focus on providing more detailed information on appropriateness of DXA screening indications (e.g. age thresholds) in order to avoid DXA overuse.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5305-0) contains supplementary material, which is available to authorized users.

The role of carboxy-terminal cross-linking telopeptide of type I collagen, dual x-ray absorptiometry bone strain and Romberg test in a new osteoporotic fracture risk evaluation: A proposal from an observational study

The consolidated way of diagnosing and treating osteoporosis in order to prevent fragility fractures has recently been questioned by some papers, which complained of overdiagnosis and consequent overtreatment of this pathology with underestimating other causes of the fragility fractures, like falls. A new clinical approach is proposed for identifying the subgroup of patients prone to fragility fractures. This retrospective observational study was conducted from January to June 2015 at the Nuclear Medicine-Bone Metabolic Unit of the of the Fondazione IRCCS Ca' Granda, Milan, Italy. An Italian population of 125 consecutive postmenopausal women was investigated for bone quantity and bone quality. Patients with neurological diseases regarding balance and vestibular dysfunction, sarcopenia, past or current history of diseases and use of drugs known to affect bone metabolism were excluded. Dual X-ray absorptiometry was used to assess bone quantity (bone mineral density) and bone quality (trabecular bone score and bone strain). Biochemical markers of bone turnover (type I collagen carboxy-terminal telopeptide, alkaline phosphatase, vitamin D) have been measured. Morphometric fractures have been searched by spine radiography. Balance was evaluated by the Romberg test. The data were evaluated with the neural network analysis using the Auto Contractive Map algorithm. The resulting semantic map shows the Minimal Spanning Tree and the Maximally Regular Graph of the interrelations between bone status parameters, balance conditions and fractures of the studied population. A low fracture risk seems to be related to a low carboxy-terminal cross-linking telopeptide of type I collagen level, whereas a positive Romberg test, together with compromised bone trabecular microarchitecture DXA parameters, appears to be strictly connected with fragility fractures. A simple assessment of the risk of fragility fracture is proposed in order to identify those frail patients at risk for osteoporotic fractures, who may have the best benefit from a pharmacological and physiotherapeutic approach.

Critical issues and current challenges in osteoporosis and fracture prevention. An overview of unmet needs

Osteoporosis is a silent disease with increasing prevalence due to the global ageing population. Decreased bone strength and bone quality is the hallmark of osteoporosis which leads to an increased risk of fragility fractures in elderly. It has been estimated that approximately ~50% of women will suffer during their lifetime from an osteoporotic fracture. This must be considered as a major health concern, as it has previously been established that fragility fracture has been associated with decreased quality of life due to increased disability, more frequent hospital admission and most importantly, osteoporotic fractures have been related to an augmented mortality risk. Anti-osteoporotic drugs are available for improving bone quality. Although there is access to these therapeutic options, there remain multiple unmet needs in the field of osteoporosis and fracture care, for example, the primary prevention of osteoporosis in young individuals (to reach a high peak bone mass), the optimization of the use of imaging techniques [dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA) and new techniques measuring bone quality], the use of nonmedical treatment options and surgical techniques of fracture healing. In this review, we will discuss topics that play a role in the occurrence and prevention of fractures, and we give an overview of and insight into the critical issues and challenges around osteoporosis and fracture prevention.

Critical issues and current challenges in osteoporosis and fracture prevention. An overview of unmet needs

Osteoporosis is a silent disease with increasing prevalence due to the global ageing population. Decreased bone strength and bone quality is the hallmark of osteoporosis which leads to an increased risk of fragility fractures in elderly. It has been estimated that approximately ~50% of women will suffer during their lifetime from an osteoporotic fracture. This must be considered as a major health concern, as it has previously been established that fragility fracture has been associated with decreased quality of life due to increased disability, more frequent hospital admission and most importantly, osteoporotic fractures have been related to an augmented mortality risk. Anti-osteoporotic drugs are available for improving bone quality. Although there is access to these therapeutic options, there remain multiple unmet needs in the field of osteoporosis and fracture care, for example, the primary prevention of osteoporosis in young individuals (to reach a high peak bone mass), the optimization of the use of imaging techniques [dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA) and new techniques measuring bone quality], the use of nonmedical treatment options and surgical techniques of fracture healing. In this review, we will discuss topics that play a role in the occurrence and prevention of fractures, and we give an overview of and insight into the critical issues and challenges around osteoporosis and fracture prevention.

A graphical clinical decision aid for managing imaging report information

OBJECTIVE

The purpose of this article is to propose a graphical decision aid for managing radiology report information to assist learners in developing clinical decision-making skills through a structured approach.

METHODS

A graphical decision aid informed by learning theories was constructed to manage radiology report information by identifying an overall strategy, specific decision-making steps, and decision goals. A review of radiology reports was performed to demonstrate the rich source of complex information requiring clinical decision making. Radiology report data were descriptively analyzed, and findings were described as definite or indefinite, while recommendations were reported as required or optional.

RESULTS

The graphical decision aid involves 4 stages. The 1st 2 stages interpret report information and consider data obtained during the clinical encounter. The following 2 stages guide decisions by answering questions to ensure patient safety and/or to confirm diagnosis and to address broader case management questions. The mean (SD) age of participants whose imaging reports were reviewed was 73.4 (7.0) years. Of 170 reports, common findings included degenerative disc disease (98%), soft tissue or vascular calcification (94%), bone demineralization (92%), and zygapophyseal joint degeneration (86%). Common indefinite findings were spinal stenosis (15%), compression fracture (12%), bony abnormality (12%), radiodensity (12%), and disc degeneration (10%). One hundred twenty-one recommendations suggested follow-up actions.

CONCLUSIONS

Information within imaging reports requires identification and interpretation to inform complex clinical decisions. The graphical decision aid proposed in this article is designed to facilitate the development of decision-making skills by providing a structured and evidence-based information management process.

Chronic low back pain and its association with lumbar vertebrae and intervertebral disc changes in adults. A case control study

AIM

This study was done to determine the association between chronic low back pain and vertebral fractures, intervertebral disc space (IDS) narrowing, vertebral osteophytes and spondylolisthesis among adults.

METHOD

This case control study was done in Sri Lanka. Cases were patients with low back pain and controls were without low back pain. Postero-anterior and lateral radiographs of lumbar sacral spine of both groups were studied. To detect vertebral fractures in fourth and fifth lumbar vertebrae, anterior and posterior heights of vertebrae were measured using a Vernier caliper and antero-posterior ratio (A/P) was calculated. Having an A/P ratio value of < 0.89 was considered as a vertebral fracture. Presence of disc space narrowing, vertebral osteophytes and spondylolisthesis was assessed by two radiologists working independently. Bivariate and logistic regression analysis was done to find associations.

RESULTS

There were 140 cases and 140 controls. Mean (SD) age for cases was 51.6 (17) years. Mean (SD) age for controls was 50 (15) years. Females made up 62% of cases and controls. Fifth lumbar vertebral fracture (odds ratio [OR] = 10.2; P = 0.001), fourth lumbar vertebral fracture (OR = 2.5; P = 0.017) and IDS narrowing (OR = 4.15, P = 0.009) had a significant association with low back pain and vertebral osteophytes and spondylolisthesis did not have a significant association with low back pain.

CONCLUSION

Only vertebral fractures and IDS narrowing had a significant association with chronic low back pain.

Increased Bone Mass in Female Mice Lacking Mast Cell Chymase

Here we addressed the potential impact of chymase, a mast-cell restricted protease, on mouse bone phenotype. We show that female mice lacking the chymase Mcpt4 acquired a persistent expansion of diaphyseal bone in comparison with wild type controls, reaching a 15% larger diaphyseal cross sectional area at 12 months of age. Mcpt4-/- mice also showed increased levels of a bone anabolic serum marker and higher periosteal bone formation rate. However, they were not protected from experimental osteoporosis, suggesting that chymase regulates normal bone homeostasis rather than the course of osteoporosis. Further, the absence of Mcpt4 resulted in age-dependent upregulation of numerous genes important for bone formation but no effects on osteoclast activity. In spite of the latter, Mcpt4-/- bones had increased cortical porosity and reduced endocortical mineralization. Mast cells were found periosteally and, notably, bone-proximal mast cells in Mcpt4-/- mice were degranulated to a larger extent than in wild type mice. Hence, chymase regulates degranulation of bone mast cells, which could affect the release of mast cell-derived factors influencing bone remodelling. Together, these findings reveal a functional impact of mast cell chymase on bone. Further studies exploring the possibility of using chymase inhibitors as a strategy to increase bone volume may be warranted.

Anti-Osteoporosis Medication Prescriptions and Incidence of Subsequent Fracture Among Primary Hip Fracture Patients in England and Wales: An Interrupted Time-Series Analysis

In January 2005, the National Institute for Health and Care Excellence (NICE) in England and Wales provided new guidance on the use of antiosteoporosis therapies for the secondary prevention of osteoporotic fractures. This was shortly followed in the same year by market authorization of a generic form of alendronic acid within the UK. We here set out to estimate the actual practice impact of these events among hip fracture patients in terms of antiosteoporosis medication prescribing and subsequent fracture incidence using primary care data (Clinical Practice Research Datalink) from 1999 to 2013. Changes in level and trend of prescribing and subsequent fracture following publication of NICE guidance and availability of generic alendronic acid were estimated using an interrupted time series analysis. Both events were considered in combination within a 1-year "intervention period." We identified 10,873 primary hip fracture patients between April 1999 and Sept 2012. Taking into account prior trend, the intervention period was associated with an immediate absolute increase of 14.9% (95% CI, 10.9 to 18.9) for incident antiosteoporosis prescriptions and a significant and clinically important reduction in subsequent major and subsequent hip fracture: -0.19% (95% CI, -0.28 to -0.09) and -0.17% (95% CI, -0.26 to -0.09) per 6 months, respectively. This equated to an approximate 14% (major) and 22% (hip) reduction at 3 years postintervention relative to expected values based solely on preintervention level and trend. We conclude that among hip fracture patients, publication of NICE guidance and availability of generic alendronic acid was temporally associated with increased prescribing and a significant decline in subsequent fractures. © 2016 American Society for Bone and Mineral Research.

Predicting Trabecular Bone Stiffness from Clinical Cone-Beam CT and HR-pQCT Data; an In Vitro Study Using Finite Element Analysis

Stiffness and shear moduli of human trabecular bone may be analyzed in vivo by finite element (FE) analysis from image data obtained by clinical imaging equipment such as high resolution peripheral quantitative computed tomography (HR-pQCT). In clinical practice today, this is done in the peripheral skeleton like the wrist and heel. In this cadaveric bone study, fourteen bone specimens from the wrist were imaged by two dental cone beam computed tomography (CBCT) devices and one HR-pQCT device as well as by dual energy X-ray absorptiometry (DXA). Histomorphometric measurements from micro-CT data were used as gold standard. The image processing was done with an in-house developed code based on the automated region growing (ARG) algorithm. Evaluation of how well stiffness (Young’s modulus E3) and minimum shear modulus from the 12, 13, or 23 could be predicted from the CBCT and HR-pQCT imaging data was studied and compared to FE analysis from the micro-CT imaging data. Strong correlations were found between the clinical machines and micro-CT regarding trabecular bone structure parameters, such as bone volume over total volume, trabecular thickness, trabecular number and trabecular nodes (varying from 0.79 to 0.96). The two CBCT devices as well as the HR-pQCT showed the ability to predict stiffness and shear, with adjusted R²-values between 0.78 and 0.92, based on data derived through our in-house developed code based on the ARG algorithm. These findings indicate that clinically used CBCT may be a feasible method for clinical studies of bone structure and mechanical properties in future osteoporosis research.

Low-trauma knee fractures in older Finnish women between 1970 and 2013

BACKGROUND

Fresh information on various low-trauma fractures of elderly adults is sparse.

AIM

We aimed to assess the current trends in the low-trauma knee fractures among older adults in Finland, an EU country with a well-defined white population of 5.4 million.

METHODS

The rates of elderly Finns' low-trauma fractures of the knee (distal femur, patella, and proximal tibia) were assessed by taking into account 60-year-old or older persons who were admitted to Finnish hospitals for primary treatment of such injury in 1970-2013.

RESULTS

The incidence of low-trauma knee fractures among 60-year-old or older Finnish women sharply rose between 1970 and 1997, from 55 fractures (per 100,000 persons) in 1970 to 124 fractures in 1997. Thereafter, the incidence continuously declined so that the fracture incidence was 91 in 2013. The corresponding age-adjusted fracture incidences were 60 (1970), 119 (1997), and 83 (2013). In older men, the fracture incidence was rather steady over time: the age-adjusted incidence was 30 in 1970 vs. 28 in 2013.

CONCLUSIONS

The rise in the incidence of low-trauma knee fractures in Finnish older women from early 1970s until late 1990s has been followed by a continuous decline in the fracture rate. Reasons for the decline are unknown, but a cohort effect toward a healthier aging female population with improved functionality and decreased risk of injurious slips, trips, and falls could partly explain the observation.

Risk of hip, subtrochanteric, and femoral shaft fractures among mid and long term users of alendronate: nationwide cohort and nested case-control study

OBJECTIVES

 To determine the skeletal safety and efficacy of long term (≥10 years) alendronate use in patients with osteoporosis.

DESIGN

 Open register based cohort study containing two nested case control studies.

SETTING

 Nationwide study of population of Denmark.

PARTICIPANTS

 61 990 men and women aged 50-94 at the start of treatment, who had not previously taken alendronate, 1996-2007.

INTERVENTIONS

 Treatment with alendronate.

MAIN OUTCOME MEASURES

 Incident fracture of the subtrochanteric femur or femoral shaft (ST/FS) or the hip. Non-fracture controls from the cohort were matched to fracture cases by sex, year of birth, and year of initiation of alendronate treatment. Conditional logistic regression models were fitted to calculate odds ratios with and without adjustment for comorbidity and comedications. Sensitivity analyses investigated subsequent treatment with other drugs for osteoporosis.

RESULTS

 1428 participants sustained a ST/FS (incidence rate 3.4/1000 person years, 95% confidence interval 3.2 to 3.6), and 6784 sustained a hip fracture (16.2/1000 person years, 15.8 to 16.6). The risk of ST/FS was lower with high adherence to treatment with alendronate (medication possession ratio (MPR, a proxy for compliance) >80%) compared with poor adherence (MPR <50%; odds ratio 0.88, 0.77 to 0.99; P=0.05). Multivariable adjustment attenuated this association (adjusted odds ratio 0.88, 0.77 to 1.01; P=0.08). The risk was no higher in long term users (≥10 dose years; 0.70, 0.44 to 1.11; P=0.13) or in current compared with past users (0.91, 0.79 to 1.06; P=0.22). Similarly, MPR >80% was associated with a decreased risk of hip fracture (0.73, 0.68 to 0.78; P<0.001) as was longer term cumulative use for 5-10 dose years (0.74, 0.67 to 0.83; P<0.001) or ≥10 dose years (0.74, 0.56 to 0.97; P=0.03).

CONCLUSIONS

 These findings support an acceptable balance between benefit and risk with treatment with alendronate in terms of fracture outcomes, even for over 10 years of continuous use.

Rationale for Strengthening Muscle to Prevent Falls and Fractures: A Review of the Evidence

Falls represent a major public health problem in older people, predominantly due to the resulting injuries which lead to progressive disability, immobilization and resulting comorbidities, dependency, institutionalization, and death. Reduced muscle strength and power have been consistently identified as risk factors for falls and related injuries, and it is likely these associations result from the central role played by reduced muscle strength and power in poor balance recovery. In addition, muscle strength and power are involved with protective responses that reduce the risk of an injury if a fall occurs. Progressive resistance training (PRT) is the standard way to increase muscle strength and power, and this training forms one of the main components of fall prevention exercise interventions. However, PRT has rarely been implemented in routine practice due to multiple challenges inherent to frail older people. The ongoing development of drugs expected to increase muscle power offers a new opportunity to reduce the risk of falls and fall-related injuries. The intent here is not to replace exercise training with drugs but rather to offer a pharmacologic alternative when exercise is not possible or contraindicated. The target population would be those most likely to benefit from this mechanism of action, i.e., weak older people without major causes for falls independent of muscle weakness. Provided such a tailored strategy was followed, a muscle anabolic may address this major unmet need.

Recent Clinical Trials in Osteoporosis: A Firm Foundation or Falling Short?

The global burden of osteoporotic fractures is associated with significant morbidity, mortality, and healthcare costs. We examined the ClinicalTrials.gov database to determine whether recently registered clinical trials addressed prevention and treatment in those at high risk for fracture. A dataset of 96,346 trials registered in ClinicalTrials.gov was downloaded on September 27, 2010. At the time of the dataset download, 40,970 interventional trials had been registered since October 1, 2007. The osteoporosis subset comprised 239 interventional trials (0.6%). Those trials evaluating orthopedic procedures were excluded. The primary purpose was treatment in 67.0%, prevention in 20.1%, supportive care in 5.8%, diagnostic in 2.2%, basic science in 3.1%, health services research in 0.9%, and screening in 0.9%. The majority of studies (61.1%) included drug-related interventions. Most trials (56.9%) enrolled only women, 38.9% of trials were open to both men and women, and 4.2% enrolled only men. Roughly one fifth (19.7%) of trials excluded research participants older than 65 years, and 33.5% of trials excluded those older than 75 years. The funding sources were industry in 51.0%, the National Institutes of Health in 6.3%, and other in 42.7%. We found that most osteoporosis-related trials registered from October 2007 through September 2010 examined the efficacy and safety of drug treatment, and fewer trials examined prevention and non-drug interventions. Trials of interventions that are not required to be registered in ClinicalTrials.gov may be underrepresented. Few trials are specifically studying osteoporosis in men and older adults. Recently registered osteoporosis trials may not sufficiently address fracture prevention.

Relationship between antipsychotic medication, serum prolactin levels and osteoporosis/osteoporotic fractures in patients with schizophrenia: a critical literature review

INTRODUCTION

Using an antipsychotic medication can increase prolactin (PRL) levels, causing hyperprolactinemia (HPRL). Although the occurrence of osteoporosis within the population of patients with schizophrenia has been recognized, the precise nature of the association between antipsychotic treatment, PRL, osteoporosis, and the disease itself seems to be elusive.

AREAS COVERED

The aim of this review is to critically review the literature regarding the association between osteoporosis and PRL and to summarize the available evidence with respect to the impact of PRL-elevating antipsychotics on bone mineral density (BMD) and fractures in non-elderly patients with schizophrenia.

EXPERT OPINION

Although long-standing HPRL can have an impact on the rate of bone metabolism and, when associated with hypogonadism, may lead to decreased bone density in both female and male subjects, the relative contribution of antipsychotic-induced HPRL in bone mineral loss in patients with schizophrenia remains unclear. Methodological shortcomings of existing studies, including the lack of prospective data and the focus on measurements of BMD instead of bone turnover markers, preclude definitive conclusions regarding the relationship between PRL-raising antipsychotics and BMD loss in patients with schizophrenia. Therefore, more well conducted prospective trials of these biomarkers are necessary to establish the precise relationship between antipsychotics, PRL levels and osteoporosis/osteoporotic risk.