A review of Paget's disease of bone with a focus on the efficacy and safety of zoledronic acid 5 mg

The pathological anatomical collection of the Natural History Museum Vienna

The pathological anatomical collection Vienna (Pathologisch-Anatomische Sammlung Wien; PASW) is a living and still growing research collection. It was established as early as 1796 as part of the Medical University of Vienna, acquired the status of an independent federal museum in 1971, and was assigned to the Natural History Museum Vienna in 2012. It houses a wide range of human wet and dry specimens and further objects, such as moulages, medical devices, microbiological and histological specimens, and a photo archive (approximately 50,000 objects), which, as a meaningful source, may contribute to disclosing not only aspects of the medical history and the development of corresponding museums in Vienna, but is also considered a collection of cultural and current scientific relevance, quite comparable to today's biobanks. Most of the tissue amassment represents wet organic specimens and human skeletons or skeletal elements representing, e.g., congenital and metabolic disorders, infectious diseases, injuries, neoplasms, or musculoskeletal diseases, basically collected as descriptive anatomical teaching aids. This article reviews the current medical issues on which research has been and is being conducted by including PASW specimens (hereby using the ICD-10 code), and the extent to and ethical conditions under which this important heritage could be used as a reference collection for clinical and bioanthropological (paleopathological and palaeoepidemiological) studies; finally, this article reflects on the value and future research prospects, taking into account different positions and the ongoing discussions in pathological anatomical human tissue collections.

Monostotic Paget's Disease Involving the Scapula Encountered Incidentally on a Trans-arterial Aortic Valve Implantation Scan

Paget's disease of the bone is a chronic bone disorder. However, to our knowledge, only a few cases of Paget's disease with isolated scapular involvement have been documented in the literature. In this case study, we describe an 81-year-old male patient who was incidentally diagnosed with monostotic Paget's disease of the left scapula during a computed tomography scan for the placement of a trans-arterial aortic valve. We discuss how crucial it is to recognise typical imaging appearances in order to prevent unnecessary investigations and interventions.

Extensive protein expression changes induced by pamidronate in RAW 264.7 cells as determined by IP-HPLC

Background

Bisphosphonate therapy has become a popular treatment for osteoporosis, Paget’s disease, multiple myeloma, osteogenesis imperfecta, myocardial infarction, and cancer despite its serious side effects. Bisphosphonate-induced molecular signaling changes in cells are still not clearly elucidated.

Methods

As bisphosphonates are primarily engulfed by macrophages, we treated RAW 264.7 cells (a murine macrophage cell line) with pamidronate and investigated global protein expressional changes in cells by immunoprecipitation high performance liquid chromatography (IP-HPLC) using 218 antisera.

Results

Pamidronate upregulated proliferation-activating proteins associated with p53/Rb/E2F and Wnt/β-catenin pathways, but downregulated the downstream of RAS signaling, pAKT1/2/3, ERK-1, and p-ERK-1, and subsequently suppressed cMyc/MAX/MAD network. However, in situ proliferation index of pamidronate-treated RAW264.7 cells was slightly increased by 3.2% vs. non-treated controls. Pamidronate-treated cells showed increase in the expressions of histone- and DNA methylation-related proteins but decrease of protein translation-related proteins. NFkB signaling was also suppressed as indicated by the down-regulations of p38 and p-p38 and the up-regulation of mTOR, while the protein expressions related to cellular protection, HSP-70, NRF2, JNK-1, and LC3 were upregulated. Consequently, pamidronate downregulated the protein expressions related to immediate inflammation,cellular differentiation, survival, angiogenesis, and osteoclastogenesis, but upregulated PARP-1 and FAS-mediated apoptosis proteins. These observations suggest pamidronate affects global protein expressions in RAW 264.7 cells by stimulating cellular proliferation, protection, and apoptosis but suppressing immediate inflammation, differentiation, osteoclastogenesis, and angiogenesis. Accordingly, pamidronate appears to affect macrophages in several ways eliciting not only its therapeutic effects but also atypical epigenetic modification, protein translation, RAS and NFkB signalings. Therefore, our observations suggest pamidronate-induced protein expressions are dynamic, and the affected proteins should be monitored by IP-HPLC to achieve the therapeutic goals during treatment.

Healthcare Resource Utilization and Direct Medical Costs for Patients With Osteoporotic Fractures in China

OBJECTIVES

To estimate annual healthcare resource utilization and direct medical costs for patients with osteoporotic fractures in China.

METHODS

Data were obtained from the Tianjin Urban Employee Basic Medical Insurance database (2008-2011). Included patients were 50 years or older with one or more diagnoses of osteoporotic fractures between 2009 and 2010. The annual healthcare resource utilization and direct medical costs were estimated. Regression model was applied to identify factors associated with the direct medical costs.

RESULTS

A total of 5941 patients were included (mean age, 65.9 years; women, 62.1%; retired, 88.2%). During the 12 months after a fracture, the annual mean all-cause cost was $2549 per patient. Osteoporosis-related costs accounted for 53.8% of the total costs; 92.0% of these costs were for inpatient services. For osteoporosis-related health services, 33.2% of the patients experienced at least 1 hospitalization, with a mean cost of $3010 per admission; 83.2% of the patients experienced at least 1 outpatient visit, with a mean cost of $18 per visit during the 12-month follow-up period. The regression model revealed that osteoporosis-related costs tended to increase with age, and patients with hip, vertebral, lower leg, and multiple fractures were more likely to have higher costs.

CONCLUSIONS

Costs for patients with osteoporotic fractures were considerable in China, driven mainly by osteoporosis-related hospitalizations. Efforts focused on reducing the utilization of inpatient services by lowering the fracture risks may lighten the economic burden of osteoporotic fractures in China.

The economic burden of fracture patients with osteoporosis in western China

To study the cost of osteoporotic fracture in China, we performed a prospective study and compared the costs of the disease in referral patients with fractures in three of the most common sites. Our results indicated that the economic burden of osteoporotic fracture to both Chinese patients and the nation is heavy.

INTRODUCTION

This paper aims to study the cost of osteoporotic fracture in China and thus to provide essential information about the burden of this disease to individuals and society.

METHODS

This prospective observational data collection study assessed the cost related to hip, vertebral, and wrist fracture 1 year after the fracture based on a patient sample consisting of 938 men and women. Information was collected using patient records, registry sources, and patient interviews. Both direct medical, direct non-medical, and indirect non-medical costs were considered.

RESULTS

The annual total costs were highest in hip fracture patients (renminbi, RMB 27,283 or USD 4,330, with confidence interval (RMB 25715, 28851)), followed by patients with vertebral fracture (RMB 21,474 or USD 3,409, with confidence interval (RMB 20082, 22866)) and wrist fracture (RMB 8,828 or USD 1,401, with confidence interval (RMB 7829, 9827)). The direct medical care costs averaged approximately RMB 17,007 per year per patient, of which inpatient costs, drugs, and investigations accounted for the majority of the costs. Nonmedical direct costs were much less compared to direct healthcare costs and averaged approximately RMB 1,846.

CONCLUSION

These results indicate that the economic burden of osteoporotic fracture to both Chinese patients and China was heavy, and the proportion of the costs in China demonstrated many similar features and some significant differences compared to other countries.

Biomedical applications of bisphosphonates

Since their discovery over 100 years ago, bisphosphonates have been used industrially as corrosion inhibitors and complexing agents. With the discovery of their pharmacological activity in the late 1960s, implicating their high affinity for hydroxyapatite, bisphosphonates have been employed in the treatment of bone diseases and as targeting agents for colloids and drugs. They have notably been investigated for the treatment of Paget's disease, osteoporosis, bone metastases, malignancy-associated hypercalcemia, and pediatric bone diseases. Currently, they are first-line medications for several of these diseases and are taken by millions of patients worldwide, mostly postmenopausal women. A major problem associated with their use is their low oral bioavailability. Several delivery systems have been proposed to improve their absorption and to direct them to sites other than bone tissues. Beyond their important pharmacological role, the medical applications of bisphosphonates are numerous. In addition, their metal-chelating properties have been exploited to coat and stabilize implants, nanoparticulates, and contrast agents. In this contribution, we review the pharmacological and clinical uses of bisphosphonates and highlight their novel applications in the pharmaceutical and biomedical fields.

Monostotic Paget's disease involving the calcaneus encountered incidentally on bone scintigraphy

Isolated involvement of calcaneus with Paget's disease of bone is highly unusual, with very few cases reported in the world literature. We present herein a unique 69-year-old male patient with monostotic Paget's disease of the left calcaneus discovered incidentally during a whole body bone scintigraphy. Since most bone scans are performed for evaluating osseous metastases, differentiating Paget's disease from overlapping metastases may be of significant clinical value. We discuss further the importance of whole body bone scan and other imaging modalities in establishing the correct diagnoses in such cases.

Economic burden of privately insured non-vertebral fracture patients with osteoporosis over a 2-year period in the US

This study assesses the costs of non-vertebral osteoporosis-related fractures patients compared with osteoporosis patients without fractures, focusing on the second year following a fracture. Since fracture patients remained more costly in the second year, their economic burden extends beyond the year in which the fracture occurs.

INTRODUCTION

The purpose of this study is to examine the comorbidity profile, resource use, and direct costs of patients who incur osteoporosis-related non-vertebral (NV) fractures in the United States during the 2 years following an incident fracture, focusing on the second year following a fracture.

METHODS

Osteoporosis patients (ICD-9-CM: 733.0) with a NV fracture (hip, femur, pelvis, lower leg, upper arm, forearm, rib, and multiple sites) were selected from a privately insured health insurance claims database (>8 million lives, ages 18-64, 1999-2006). These NV fracture patients were randomly matched 1:1 on age, gender, employment status, and geographic region to controls with osteoporosis but without a fracture history. Year-by-year and month-by-month rates of comorbidities, resource use, and direct costs were calculated for the matched sample (N = 3,781).

RESULTS

Comorbidity rates and resource use remained significantly higher among NV fracture patients during second year following an NV fracture compared with controls, although absolute rates of comorbidities and service utilization declined. Mean direct excess costs for NV fracture patients fell from $5,267 in the first year to $2,072 in the second year after a fracture, but remained statistically significant (p < 0.01). Patients with fractures of the pelvis, hip, and femur had the highest excess costs in the second year ($5,121, $3,930, and $3,828, respectively). Although hip fractures had highest excess costs over both years, non-vertebral, non-hip fracture patients made up a larger proportion of the sample and were significantly more costly than controls.

CONCLUSIONS

Patients with osteoporosis-related NV fractures have substantial excess costs beyond the first year in which the fracture occurs.

Direct and indirect costs of non-vertebral fracture patients with osteoporosis in the US

Osteoporosis is a condition marked by low bone mineral density and the deterioration of bone tissue. One of the main clinical and economic consequences of osteoporosis is skeletal fractures. To assess the healthcare and work loss costs of US patients with non-vertebral (NV) osteoporotic fractures. Privately insured (aged 18-64 years) and Medicare (aged >/=65 years) patients with osteoporosis (ICD-9-CM code: 733.0x) were identified during 1999-2006 using two claims databases. Patients with an NV fracture (femur, pelvis, lower leg, upper arm, forearm, rib or hip) were matched randomly on age, sex, employment status and geographic region to controls with osteoporosis and no fractures. Patient characteristics and annual healthcare costs were assessed over the year following the index fracture for privately insured (n = 4764) and Medicare (n = 48 742) beneficiaries (Medicare drug costs were estimated using multivariable models). Indirect (i.e. work loss) costs were calculated for a subset of privately insured, employed patients with available disability data (n = 1148). All costs were reported in $US, year 2006 values. In Medicare, mean incremental healthcare costs per NV fracture patient were $US13 387 ($US22 466 vs $US9079; p < 0.05). The most expensive patients had index fractures of the hip, multiple sites and femur (incremental costs of $US25 519, $US20 137 and $US19 403, respectively). Patients with NV non-hip (NVNH) fractures had incremental healthcare costs of $US7868 per patient ($US16 704 vs $US8836; p < 0.05). Aggregate annual incremental healthcare costs of NVNH patients in the Medicare research sample (n = 35 933) were $US282.7 million compared with $US204.1 million for hip fracture patients (n = 7997). Among the privately insured, mean incremental healthcare costs per NV fracture patient were $US5961 ($US11 636 vs $US5675; p < 0.05). The most expensive patients had index fractures of the hip, multiple sites and pelvis (incremental costs of $US13 801, $US9642 and $US8164, respectively). Annual incremental healthcare costs per NVNH patient were $US5381 ($US11 090 vs $US5709; p < 0.05). Aggregate annual incremental healthcare costs of NVNH patients in the privately insured sample (n = 4478) were $US24.1 million compared with $US3.5 million for hip fracture patients (n = 255). Mean incremental work loss costs per NV fracture employee were $US1956 ($US4349 vs $US2393; p < 0.05). Among patients with available disability data, work loss accounted for 29.5% of total costs per NV fracture employee. The cost burden of NV fracture patients to payers is substantial. Although hip fracture patients were more costly per patient in both Medicare and privately insured samples, NVNH fracture patients still had substantial incremental costs. Because NVNH patients accounted for a larger proportion of the fracture population, they were associated with greater aggregate incremental healthcare costs than hip fracture patients.