FRAX®: prediction of major osteoporotic fractures in women from the general population: the OPUS study

Validity of Major Osteoporotic Fracture Diagnoses in the Danish National Patient Registry

Objective

To evaluate the validity of diagnosis codes for Major Osteoporotic Fracture (MOF) in the Danish National Patient Registry (NPR) and secondly to evaluate whether the fracture was incident/acute using register-based definitions including date criteria and procedural codes.

Methods

We identified a random sample of 2400 records with a diagnosis code for a MOF in the NPR with dates in the year of 2018. Diagnoses were coded with the 10th revision of the International Classification of Diseases (ICD-10). The sample included 2375 unique fracture patients from the Region of Southern Denmark. Medical records were retrieved for the study population and reviewed by an algorithmic search function and medical doctors to verify the MOF diagnoses. Register-based definitions of incident/acute MOF was evaluated in NPR data by applying date criteria and procedural codes.

Results

The PPV for MOF diagnoses overall was 0.99 (95% CI: 0.98;0.99) and PPV=0.99 for the four individual fracture sites, respectively. Further, analyses of incident/acute fractures applying date criteria, procedural codes and using patients' first contact in the NPR resulted in PPV=0.88 (95% CI: 0.84;0.91) for hip fractures, PPV=0.78 (95% CI: 0.74;0.83) for humerus fractures, PPV=0.78 (95% CI: 0.73;0.83) for clinical vertebral fractures and PPV=0.87 (95% CI: 0.83;0.90) for wrist fractures.

Conclusion

ICD-10 coded MOF diagnoses are valid in the NPR. Furthermore, a set of register-based criteria can be applied to qualify if the MOF fracture was incident/acute. Thus, the NPR is a valuable and reliable data source for epidemiological research on osteoporotic fractures.

A systematic review on the performance of fracture risk assessment tools: FRAX, DeFRA, FRA-HS

PURPOSE

Preventing fragility fractures by treating osteoporosis may reduce disability and mortality worldwide. Algorithms combining clinical risk factors with bone mineral density have been developed to better estimate fracture risk and possible treatment thresholds. This systematic review supported panel members of the Italian Fragility Fracture Guidelines in recommending the use of best-performant tool. The clinical performance of the three most used fracture risk assessment tools (DeFRA, FRAX, and FRA-HS) was assessed in at-risk patients.

METHODS

PubMed, Embase, and Cochrane Library were searched till December 2020 for studies investigating risk assessment tools for predicting major osteoporotic or hip fractures in patients with osteoporosis or fragility fractures. Sensitivity (Sn), specificity (Sp), and areas under the curve (AUCs) were evaluated for all tools at different thresholds. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2; certainty of evidence (CoE) was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Forty-three articles were considered (40, 1, and 2 for FRAX, FRA-HS, and DeFRA, respectively), with the CoE ranging from very low to high quality. A reduction of Sn and increase of Sp for major osteoporotic fractures were observed among women and the entire population with cut-off augmentation. No significant differences were found on comparing FRAX to DeFRA in women (AUC 59-88% vs. 74%) and diabetics (AUC 73% vs. 89%). FRAX demonstrated non-significantly better discriminatory power than FRA-HS among men.

CONCLUSION

The task force formulated appropriate recommendations on the use of any fracture risk assessment tools in patients with or at risk of fragility fractures, since no statistically significant differences emerged across different prediction tools.

Validation of a genome-wide polygenic score in improving fracture risk assessment beyond the FRAX tool in the Women's Health Initiative study

BACKGROUND

Previous study has established two polygenic scores (PGSs) related to femoral neck bone mineral density (BMD) (PGS_FNBMDldpred) and total body BMD (PGS_TBBMDldpred) that are associated with fracture risk. However, these findings have not yet been externally validated in an independent cohort.

OBJECTIVES

This study aimed to validate the predictive performance of the two established PGSs and to investigate whether adding PGSs to the Fracture Risk Assessment Tool (FRAX) improves the predictive ability of FRAX in identifying women at high risk of major osteoporotic fracture (MOF) and hip fractures (HF).

METHODS

The study used the Women's Health Initiative (WHI) cohort of 9,000 postmenopausal women of European ancestry. Cox Proportional Hazard Models were used to assess the association between each PGS and MOF/HF risk. Four models were formulated to investigate the effect of adding PGSs to the FRAX risk factors: (1) Base model: FRAX risk factors; (2) Base model + PGS_FNBMDldpred; (3) Base model + PGS_TBBMDldpred; (4) Base model + metaPGS. The reclassification ability of models with PGS was further assessed using the Net Reclassification Improvement (NRI) and the Integrated discrimination improvement (IDI).

RESULTS

The study found that the PGSs were not significantly associated with MOF or HF after adjusting for FRAX risk factors. The FRAX base model showed moderate discrimination of MOF and HF, with a C-index of 0.623 (95% CI, 0.609 to 0.641) and 0.702 (95% CI, 0.609 to 0.718), respectively. Adding PGSs to the base FRAX model did not improve the ability to discriminate MOF or HF. Reclassification analysis showed that compared to the model without PGS, the model with PGS_TBBMDldpred (1.2%, p = 0.04) and metaPGS (1.7%, p = 0.05) improve the reclassification of HF, but not MOF.

CONCLUSIONS

The findings suggested that incorporating genetic information into the FRAX tool has minimal improvement in predicting HF risk for elderly Caucasian women. These results highlight the need for further research to identify other factors that may contribute to fracture risk in elderly Caucasian women.

Development and validation of the fall-related injury risk in nursing homes (INJURE-NH) prediction tool

BACKGROUND

Existing models to predict fall-related injuries (FRI) in nursing homes (NH) focus on hip fractures, yet hip fractures comprise less than half of all FRIs. We developed and validated a series of models to predict the absolute risk of FRIs in NH residents.

METHODS

Retrospective cohort study of long-stay US NH residents (≥100 days in the same facility) between January 1, 2016 and December 31, 2017 (n = 733,427) using Medicare claims and Minimum Data Set v3.0 clinical assessments. Predictors of FRIs were selected through LASSO logistic regression in a 2/3 random derivation sample and tested in a 1/3 validation sample. Sub-distribution hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated for 6-month and 2-year follow-up. Discrimination was evaluated via C-statistic, and calibration compared the predicted rate of FRI to the observed rate. To develop a parsimonious clinical tool, we calculated a score using the five strongest predictors in the Fine-Gray model. Model performance was repeated in the validation sample.

RESULTS

Mean (Q1, Q3) age was 85.0 (77.5, 90.6) years and 69.6% were women. Within 2 years of follow-up, 43,976 (6.0%) residents experienced ≥1 FRI. Seventy predictors were included in the model. The discrimination of the 2-year prediction model was good (C-index = 0.70), and the calibration was excellent. Calibration and discrimination of the 6-month model were similar (C-index = 0.71). In the clinical tool to predict 2-year risk, the five characteristics included independence in activities of daily living (ADLs) (HR 2.27; 95% CI 2.14-2.41) and a history of non-hip fracture (HR 2.02; 95% CI 1.94-2.12). Performance results were similar in the validation sample.

CONCLUSIONS

We developed and validated a series of risk prediction models that can identify NH residents at greatest risk for FRI. In NH, these models should help target preventive strategies.

Discrepancies in type of first major osteoporotic fracture and anti-osteoporotic therapy in elderly people with type 2 diabetes mellitus: A retrospective Danish cohort study

OBJECTIVE

Subjects with diabetes mellitus have an increased risk of fractures. We aimed to identify discrepancies in the first type of major osteoporotic fracture (MOF) and anti-osteoporotic therapy between subjects with type 2 diabetes (T2D) and subjects without diabetes. Methods and research design. We conducted a retrospective national cohort study by access to all discharge diagnoses (ICD-10 system) and redeemed drug prescriptions (ATC classification system). We included all subjects alive and Danish citizens in 2010 and identified subjects with T2D diagnosed after the age of 50 between 1998 and 2018. Only subjects with a MOF after the index date were included in the main analysis. The type of MOF was identified by diagnosis codes and categorized into Humerus, Forearm, Spine, and Hip. Multinomial logistic regression modeling was used to assess the predicted probability changes in MOF type between T2D and control subjects. Data on first anti-osteoporotic therapy after the MOF was assessed by redeemed drug prescriptions. Mortality and time to therapy after the MOF were evaluated by cox proportional hazards.

RESULT

We included 26,588 subjects with T2D and 97,982 subjects without diabetes. The mean age was age 69.33 (±10.34) for T2D and 69.85 (±10.19) for control subjects. The cohort was primarily females (67 %). Subjects with T2D had a higher probability of hip (3.98 % [95 % CI 3.29; 4.67]) and humerus (2.82 % [95 % CI 2.17; 3.46]) fractures as the first MOF compared to control subjects. However, the probability of forearm fractures as the first MOF was 6.77 % (95 % CI 6.08; 7.46) lower among subjects with T2D. The multiple adjusted hazard ratio for anti-osteoporotic treatment after the first MOF was 0.80 (95 % CI 0.77; 0.88) for T2D compared to controls among treatment-naïve subjects.

CONCLUSION

Forearm fractures were the most frequent type of MOF and were more prevalent in control subjects. Subjects with T2D had a significantly higher probability of hip and humerus fractures as the first MOF but had a 20 % lower chance of anti-osteoporotic treatment afterwards.

The clinical utility of the BMD-related comprehensive genome-wide polygenic score in identifying individuals with a high risk of osteoporotic fractures

The potential of bone mineral density (BMD)-related genome-wide polygenic score (PGS) in identifying individuals with a high risk of fractures remains unclear. This study suggests that an efficient PGS enables the identification of strata with up to a 1.5-fold difference in fracture incidence. Incorporating PGS into clinical diagnosis is anticipated to increase the population-level screening benefits.

PURPOSE

This study sought to construct genome-wide polygenic scores for femoral neck and total body BMD and to estimate their potential in identifying individuals with a high risk of osteoporotic fractures.

METHODS

Genome-wide polygenic scores were developed and validated for femoral neck and total body BMD. We externally tested the PGSs, both by themselves and in combination with available clinical risk factors, in 455,663 European ancestry individuals from the UK Biobank. The predictive accuracy of the developed genome-wide PGS was also compared with previously published restricted PGS employed in fracture risk assessment.

RESULTS

For each unit decrease in PGSs, the genome-wide PGSs were associated with up to 1.17-fold increased fracture risk. Out of four studied PGSs, [Formula: see text] (HR: 1.03; 95%CI 1.01-1.05, p = 0.001) had the weakest and the [Formula: see text] (HR: 1.17; 95%CI 1.15-1.19, p < 0.0001) had the strongest association with an incident fracture. In the reclassification analysis, compared to the FRAX base model, the models with [Formula: see text], [Formula: see text], [Formula: see text], and [Formula: see text] improved the reclassification of fracture by 1.2% (95% CI, 1.0 to 1.3%), 0.2% (95% CI, 0.1 to 0.3%), 1.4% (95% CI, 1.3 to 1.5%), and 2.2% (95% CI, 2.1 to 2.4%), respectively.

CONCLUSIONS

Our findings suggested that an efficient PGS estimate enables the identification of strata with up to a 1.7-fold difference in fracture incidence. Incorporating PGS information into clinical diagnosis is anticipated to increase the benefits of screening programs at the population level.

The influence of intra-cortical microstructure on the contrast in ultrasound images of the cortex of long bones: A 2D simulation study

Decreased thickness of the bone cortex due to bone loss in the course of ageing and osteoporosis is associated with reduced bone strength. Cortical thickness measurement from ultrasound images was recently demonstrated in young adults. This requires the identification of both the outer (periosteum) and inner (endosteum) surfaces of the bone cortex. However, with bone loss, the cortical porosity and the size of the vascular pores increase resulting in enhanced ultrasound scattering which may prevent the detection of the endosteum. The aim of this work was to study the influence of cortical bone microstructure variables, such as porosity and pore size, on the contrast of the endosteum in ultrasound images. We wanted to estimate the range of these variables for which ultrasound imaging of the endosteum is feasible. We generated synthetic data using a two-dimensional time-domain code to simulate the propagation of elastodynamic waves. A synthetic aperture imaging sequence with an array transducer operating at a center frequency of 2.5 MHz was used. The numerical simulations were conducted for 105 cortical microstructures obtained from high resolution X-ray computed tomography images of ex vivo bone samples with a porosity ranging from 2% to 24 %. Images were reconstructed using a delay-and-sum (DAS) algorithm with optimized f-number, correction of refraction at the periosteum, and sample-specific wave-speed. We observed a range variation of 18 dB of endosteum contrast in our data set depending on the bone microstructure. We found that as porosity increases, speckle intensity inside the bone cortex increases whereas the intensity of the signal from the endosteum decreases. Also, a microstructure with large pores (diameter >250 μm) was associated with poor endosteum visibility, compared with a microstructure with equal porosity but a more narrow distribution of pore sizes. These findings suggest that ultrasound imaging of the bone cortex with a probe operating at a central frequency of 2.5 MHz using refraction-corrected DAS is capable of detecting the endosteum of a cortex with moderate porosity (less than about 10%) if the largest pores remain smaller than about 200 μm.

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

Background

Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field.

Purpose

This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline.

Methods

The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations.

Results

Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively.

Conclusions

The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.

Prediction Models for Osteoporotic Fractures Risk: A Systematic Review and Critical Appraisal

Osteoporotic fractures (OF) are a global public health problem currently. Many risk prediction models for OF have been developed, but their performance and methodological quality are unclear. We conducted this systematic review to summarize and critically appraise the OF risk prediction models. Three databases were searched until April 2021. Studies developing or validating multivariable models for OF risk prediction were considered eligible. Used the prediction model risk of bias assessment tool to appraise the risk of bias and applicability of included models. All results were narratively summarized and described. A total of 68 studies describing 70 newly developed prediction models and 138 external validations were included. Most models were explicitly developed (n=31, 44%) and validated (n=76, 55%) only for female. Only 22 developed models (31%) were externally validated. The most validated tool was Fracture Risk Assessment Tool. Overall, only a few models showed outstanding (n=3, 1%) or excellent (n=32, 15%) prediction discrimination. Calibration of developed models (n=25, 36%) or external validation models (n=33, 24%) were rarely assessed. No model was rated as low risk of bias, mostly because of an insufficient number of cases and inappropriate assessment of calibration. There are a certain number of OF risk prediction models. However, few models have been thoroughly internally validated or externally validated (with calibration being unassessed for most of the models), and all models showed methodological shortcomings. Instead of developing completely new models, future research is suggested to validate, improve, and analyze the impact of existing models.

An investigation on osteoporosis based on guided wave propagation in multi-layered bone plates

In this study, the multi-layer structure of bones has been used to simulate bone loss, and the guided waves were transmitted to the double-layer structured simulated bone plates, which are cortical bone and spongy bone. The soft tissue layer was simulated by water and the theoretical solution of the multilayer structure has been established. The guided waves were excited by the laser ultrasound technique and the Recursive Asymptotic Stiffness Matrix (RASM) was used to build a multilayer structure. Results show that, as the cortical bone is thinned, the dispersion relationship curve mode shifts toward high frequency and low phase velocity. Also, as the spongy bone density decreases, the dispersion relationship curve mode moves toward high frequency and high phase velocity. Further, it is found that, as the porosity rises, the mode of the dispersion relationship curve shifts to the direction of low frequency and low phase velocity. Through the addition of soft tissues and introduction of simultaneous changes in parameters, osteoporosis can be distinguished with high accuracy and hence this method can be applied to the detection of osteoporosis in the future.

In vivopulse-echo measurement of apparent broadband attenuation andQfactor in cortical bone: a preliminary study

Quantitative ultrasound (QUS) methods have been introduced to assess cortical bone health at the radius and tibia through the assessment of cortical thickness (Ct.Th), cortical porosity and bulk wave velocities. Ultrasonic attenuation is another QUS parameter which is not currently used. We assessed the feasibility ofin vivomeasurement of ultrasonic attenuation in cortical bone with a broadband transducer with 3.5 MHz center frequency. Echoes from the periosteal and endosteal interfaces were fitted with Gaussian pulses using sparse signal processing. Then, the slope of the broadband ultrasonic attenuation (Ct.nBUA) in cortical bone and quality factorQ11-1were calculated with a parametric approach based on the center-frequency shift. Five human subjects were measured at the one-third distal radius with pulse-echo ultrasound, and reference data was obtained with high-resolution x-ray peripheral computed tomography (Ct.Th and cortical volumetric bone mineral density (Ct.vBMD)). Ct.Th was used in the calculation of Ct.nBUA whileQ11-1is obtained solely from ultrasound data. The values of Ct.nBUA (6.7 ± 2.2 dB MHz^-1.cm^-1) andQ11-1(8.6 ± 3.1%) were consistent with the literature data and were correlated to Ct.vBMD (R2=0.92,p<0.01, RMSE = 0.56 dB.MHz^-1.cm^-1, andR2=0.93,p<0.01, RMSE = 0.76%). This preliminary study suggests that the attenuation of an ultrasound signal propagating in cortical bone can be measuredin vivoat the one-third distal radius and that it provides an information on bone quality as attenuation values were correlated to Ct.vBMD. It remains to ascertain that Ct.nBUA andQ11-1measured here exactly reflect the true (intrinsic) ultrasonic attenuation in cortical bone. Measurement of attenuation may be considered useful for assessing bone health combined with the measurement of Ct.Th, porosity and bulk wave velocities in multimodal cortical bone QUS methods.

The Utility of Genetic Risk Score to Improve Performance of FRAX for Fracture Prediction in US Postmenopausal Women

The ability of the fracture risk assessment tool (FRAX) in discriminating fracture and non-fracture in postmenopausal women remains suboptimal. Adding a genetic profile may improve the performance of FRAX. Three genetic risk scores (GRSs) (GRS_fracture, GRS_BMD, GRS_eBMD) were calculated for each participant in the Women's Health Initiative Study (n = 23,981), based on the summary statistics of three comprehensive osteoporosis-related genome-wide association studies (GWAS). The primary outcomes were incident major osteoporotic fracture (MOF) and hip fracture (HF). The association between each GRS and fracture risk were evaluated in separate Cox Proportional Hazard models, with FRAX clinical risk factors adjusted for. The discrimination ability of each model was assessed using Area Under the Curve (AUC). The predictive improvement attributable to each GRSs was assessed using the net reclassification improvement (NRI) and the integrated discrimination improvement (IDI). GRS_BMD and GRS_eBMD were significantly associated with MOF and HF risk, independent of the base FRAX risk factors. Compare to the base FRAX model, the models with GRS_fracture, GRS_BMD, and GRS_eBMD improved the reclassification of MOF by 0.5% (95% CI, 0.2% to 0.9%, p = p < .01), 0.3% (95% CI, 0.1% to 0.6%, p = 0.01), and 2.1% (95% CI, 0.3% to 2.8%, p < .01), respectively. Similar results were also observed when using HF as an outcome. Our study suggested that the addition of genetic profiles provide limited improvements in the reclassification of FRAX for MOF and HF.

Osteoporosis Screening Is Often Indicated but Overlooked Prior to Rotator Cuff Repair

Purpose

To (1) report the percentage of patients undergoing rotator cuff repair (RCR) who were appropriately screened with dual-energy X-ray absorptiometry testing prior to surgery, if indicated, and (2) determine the percentage of patients properly prescribed osteoporosis medications within 6 months of surgery.

Methods

Consecutive patients aged 50 years or older who underwent elective RCR at a single tertiary-care center over a 1-year period were reviewed. Fracture risk was estimated using the Fracture Risk Assessment Tool (FRAX) with and without bone mineral density. The U.S. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied. Patients with acute fractures or revision surgery were excluded.

Results

Of the 218 patients included, 129 were women (58.1%). The mean age was 61.5 ± 7.2 years. One hundred thirty-one RCRs (60.1%) occurred within 3 months of injury. A total of 69 patients (31.7%) met the NOF criteria for bone mineral density screening. Of these patients, 23 (33.3%) were appropriately screened with a dual-energy X-ray absorptiometry scan. Primary care providers initiated bone health assessment in 18 of the 23 appropriately screened patients, with orthopaedic providers initiating the workup in 3 patients (13.0%). Thirty-two patients (14.7%) met the NOF criteria for pharmacologic management of osteoporosis. Of these patients, 5 (15.6%) were treated. Patients meeting the medication criteria were older (69.1 ± 7.7 years vs 60.2 ± 6.3 years, P < .001), had a lower body mass index (28.8 ± 6.1 vs 31.5 ± 6.5, P = .028), and had chronic rotator cuff tears (P = .015).

Conclusions

Patients aged 50 years or older undergoing RCR are often not appropriately screened for osteoporosis. Even when appropriately screened, only 15.6% of patients meeting the indications for pharmacologic intervention for bone health optimization were prescribed appropriate medications. Although bone health optimization may or may not affect surgical timing, patient encounters related to rotator cuff tears can be used as an opportunity for providers to initiate osteoporosis screening and treatment protocols.

Level of Evidence

Level IV, therapeutic case series.

Comparing three machine learning approaches to design a risk assessment tool for future fractures: predicting a subsequent major osteoporotic fracture in fracture patients with osteopenia and osteoporosis

Four machine learning models were developed and compared to predict the risk of a future major osteoporotic fracture (MOF), defined as hip, wrist, spine and humerus fractures, in patients with a prior fracture. We developed a user-friendly tool for risk calculation of subsequent MOF in osteopenia patients, using the best performing model.

INTRODUCTION

Major osteoporotic fractures (MOFs), defined as hip, wrist, spine and humerus fractures, can have serious consequences regarding morbidity and mortality. Machine learning provides new opportunities for fracture prediction and may aid in targeting preventive interventions to patients at risk of MOF. The primary objective is to develop and compare several models, capable of predicting the risk of MOF as a function of time in patients seen at the fracture and osteoporosis outpatient clinic (FO-clinic) after sustaining a fracture.

METHODS

Patients aged > 50 years visiting an FO-clinic were included in this retrospective study. We compared discriminative ability (concordance index) for predicting the risk on MOF with a Cox regression, random survival forests (RSF) and an artificial neural network (ANN)-DeepSurv model. Missing data was imputed using multiple imputations by chained equations (MICE) or RSF's imputation function. Analyses were performed for the total cohort and a subset of osteopenia patients without vertebral fracture.

RESULTS

A total of 7578 patients were included, 805 (11%) patients sustained a subsequent MOF. The highest concordance-index in the total dataset was 0.697 (0.664-0.730) for Cox regression; no significant difference was determined between the models. In the osteopenia subset, Cox regression outperformed RSF (p = 0.043 and p = 0.023) and ANN-DeepSurv (p = 0.043) with a c-index of 0.625 (0.562-0.689). Cox regression was used to develop a MOF risk calculator on this subset.

CONCLUSION

We show that predicting the risk of MOF in patients who already sustained a fracture can be done with adequate discriminative performance. We developed a user-friendly tool for risk calculation of subsequent MOF in patients with osteopenia.

Bulk Wave Velocities in Cortical Bone Reflect Porosity and Compression Strength

The goal of this study was to evaluate whether ultrasonic velocities in cortical bone can be considered as a proxy for mechanical quality of cortical bone tissue reflected by porosity and compression strength. Micro-computed tomography, compression mechanical testing and resonant ultrasound spectroscopy were used to assess, respectively, porosity, strength and velocity of bulk waves of both shear and longitudinal polarisations propagating along and perpendicular to osteons, in 92 cortical bone specimens from tibia and femur of elderly human donors. All velocities were significantly associated with strength (r = 0.65-0.83) and porosity (r = -0.64 to -0.77). Roughly, according to linear regression models, a decrease in velocity of 100 m/s corresponded to a loss of 20 MPa in strength (which is approximately 10% of the largest strength value) and to an increase in porosity of 5%. These results provide a rationale for the in vivo measurement of one or several velocities for the diagnosis of bone fragility.

The International Collaborative Gaucher Group GRAF (Gaucher Risk Assessment for Fracture) score: a composite risk score for assessing adult fracture risk in imiglucerase-treated Gaucher disease type 1 patients

Background

Fractures in Gaucher disease type 1 (GD1) patients cause significant morbidity. Fracture risk may be decreased by enzyme replacement therapy (ERT) but not eliminated. When considering initiation of treatment, it is useful to know to what extent fixed patient-specific factors determine risk for future fractures beyond standard risk factors that change with time and treatment, such as decreased bone mineral density. We developed a tool called the GRAF score (Gaucher Risk Assessment for Fracture) that applies 5 widely available characteristics (sex, age at treatment initiation [ATI], time interval between diagnosis and treatment initiation, splenectomy status, history of pre-treatment bone crisis) and provides a practical method to assess future fracture risk when imiglucerase ERT is initiated.

Methods

Inclusion criteria: GD1 patients in the International Collaborative Gaucher Group Gaucher Registry as of September 2019 initially treated with alglucerase/imiglucerase; known splenectomy status; at least one skeletal assessment on treatment (3216 of 6422 patients). Data were analyzed by ATI group (< 18, ≥ 18 to < 50, or ≥ 50 years of age) using Cox proportional hazards regression with all 5 risk factors included in the multivariable model. A composite risk score was calculated by summing the contribution of each parameter weighted by the strength of its association (regression coefficient) with fracture risk.

Results

Patients were followed from the date of treatment initiation (or age 18 years for patients if treatment started earlier) to the date of first adult fracture (n = 288 first fracture endpoints), death, or end of follow-up. The GRAF score for each ATI group was associated with a 2.7-fold increased risk of adult fracture for each one-point increase (p < 0.02 for < 18 ATI, p < 0.0001 for ≥ 18 to < 50 ATI and ≥ 50 ATI).

Conclusions

The GRAF score is a tool to be used with bone density and other modifiable, non-GD-specific risk factors (e.g. smoking, alcohol intake, frailty) to inform physicians and previously untreated GD1 patients about risk for a future fracture after starting imiglucerase regardless of whether there is an eventual switch to an alternative ERT or to substrate reduction therapy. GRAF can also help predict the extent that fracture risk increases if initiation of treatment is further delayed.

The Efficacy of Alendronate Versus Denosumab on Major Osteoporotic Fracture Risk in Elderly Patients With Diabetes Mellitus: A Danish Retrospective Cohort Study

OBJECTIVE

Patients with diabetes mellitus have an increased risk of fractures; however, the underlying mechanism is largely unknown. We aimed to investigate whether the risk of major osteoporotic fractures in diabetes patients differs between subjects initiated with alendronate and denosumab, respectively.

METHODS AND RESEARCH DESIGN

We conducted a retrospective nationwide cohort study through access to all discharge diagnoses (ICD-10 system) from the National Danish Patient Registry along with all redeemed drug prescriptions (ATC classification system) from the Health Service Prescription Registry. We identified all subjects with a diabetes diagnosis between 2000 and 2018 and collected data on the first new prescription of anti-osteoporotic treatment between 2011 and 2018. Exposure was defined as either alendronate or denosumab treatment initiated after diabetes diagnosis. Outcome information was collected by identification of all major osteoporotic fracture (MOF) diagnoses, i.e., hip, spine, forearm, and humerus, from exposure until 2018 or censoring by emigration or death. The risk of fracture was calculated as hazard ratios (HR) using multiply adjusted Cox proportional models with death as a competing risk.

RESULTS

We included 8,745 subjects initiated with either alendronate (n = 8,255) or denosumab (n = 490). The cohort consisted of subjects with a mean age of 73.62 (SD ± 9.27) years, primarily females (69%) and suffering mainly from type 2 diabetes (98.22%) with a median diabetes duration at baseline of 5.45 years (IQR 2.41-9.19). Those in the denosumab group were older (mean 75.60 [SD ± 9.72] versus 73.51 [SD ± 9.23] years), had a higher proportion of women (81% versus 68%, RR 1.18 [95% CI 1.13-1.24], and were more comorbid (mean CCI 2.68 [95% CI 2.47-2.88] versus 1.98 [95% CI 1.93-2.02]) compared to alendronate initiators. In addition, denosumab users had a higher prevalence of previous fractures (64% versus 46%, RR 1.38 [95% CI 1.28-1.48]). The adjusted HR for any MOF after treatment initiation with denosumab was 0.89 (95% CI 0.78-1.02) compared to initiation with alendronate.

CONCLUSION

The risk of incident MOF among subjects with diabetes was similar between those initially treated with alendronate and denosumab. These findings indicate that the two treatment strategies are equally effective in preventing osteoporotic fractures in subjects with diabetes.

Bone Mineral Density: Clinical Relevance and Quantitative Assessment

Bone mineral density (BMD) measurement by dual-energy x-ray absorptiometry (DXA) is an internationally accepted standard-of-care screening tool used to assess fragility-fracture risk. Society guidelines have recommended which populations may benefit from DXA screening and the use of the fracture risk assessment tool (FRAX) to guide decisions regarding pharmacologic treatment for osteoporosis. According to the U.S. National Osteoporosis Foundation guidelines, postmenopausal women and men at least 50 y old with osteopenic BMD warrant pharmacologic treatment if they have a FRAX-calculated 10-y probability of at least 3% for hip fracture or at least 20% for major osteoporotic fracture. Patients with osteoporosis defined by a clinical event, namely a fragility fracture, or with an osteoporotic BMD should also be treated. Patients who are treated for osteoporosis should be monitored regularly to track expected gains in BMD by serial DXA scans. With some drug therapies, BMD targets can be reached whereby further improvements in BMD are not associated with further reductions in fracture risk. Although reaching this target might suggest a stopping point for therapy, the reversibility of most treatments for osteoporosis, except for the bisphosphonates, has dampened enthusiasm for this approach. In the case of denosumab, it is now apparent that stopping therapy at any point can lead to an increase in multiple-fracture risk. For patients who do not respond to antiosteoporosis pharmacologic therapy with an improvement in BMD, or who have an incident fragility fracture on therapy, secondary causes of osteoporosis or non-compliance with medical therapy should be considered.

Role of calcium and phosphorous concentration as an intrinsic factor in the development of skull fracture following road traffic accidents

INTRODUCTION

Traumatic brain injury (TBI) or head injury is one of the leading causes of morbidity and mortality globally. TBI includes a fractured skull as an indicator of insult which can affect the treatment outcome as well. The development of any fracture depends on a combination of factors defining the intrinsic properties of the bone and the extrinsic factors related to the impact. A decrease in bone mass secondary to deficiency of calcium (Ca) and phosphorus (P) can be a significant factor intrinsic to the skull bone, which can modulate the outcome of the impact by increasing the susceptibility of bones towards fractures. We undertook this research to find out whether or not the Ca and P concentration in skull bone has a role to play as an intrinsic factor, in the development of skull fracture following Road Traffic Accidents (RTAs).

METHODOLOGY

In this case-control study conducted for two years, we collected 94 bone samples, i.e. 47 each, from skull bones with head injuries following RTA, with (case) and without (control) fracture of the skull. The elemental analyses for the bony concentration of Ca and P in both the groups were then compared using energy dispersive X-ray (EDX). Unpaired t-test and Fisher's exact test was used for statistical analysis.

RESULTS

The elemental analysis of bones provided evidence that suggests that whilst; Ca is the only mineral that appears to have a significant correlation with the development of fracture skull, the overall Ca: P ratio of less than 1.99 increases the chances of skull fracture by 3.9 times.

CONCLUSIONS

Both individual bony Ca concentration and Ca: P ratio can be regarded as important intrinsic factors for the development of skull fracture.

Radiofrequency echographic multi spectrometry for the prediction of incident fragility fractures: A 5-year follow-up study

PURPOSE

To investigate the effectiveness of the T-score values provided by Radiofrequency Echographic Multi Spectrometry (REMS) in the identification of patients at risk for incident osteoporotic fractures.

METHODS

A population of Caucasian women (30-90 years), enrolled from 2013 to 2016, underwent dual X-ray absorptiometry (DXA) and REMS scans at axial sites. The incidence of fragility fractures was assessed during a follow-up period up to 5 years. Afterwards, patients with and without incident fractures were stratified in two age-matched groups with a 1: 2 proportion (Group F' and Group NF', respectively). The performance of REMS T-score in discriminating between the two groups was quantitatively assessed and compared with DXA.

RESULTS

1516 patients were enrolled and 1370 completed the follow-up (mean ± SD: 3.7 ± 0.8 years; range: 1.9-5.0 years). Fracture incidence was 14.0%. Age-matched groups included 175 fractured patients and 350 non-fractured ones, respectively (median age 70.2 [interquartile range: 61.0-73.3] and 67.3 [65.4-69.8] years, p-value ns). The groups resulted also balanced for height, weight and BMI (p-values ns). As expected, the differences in REMS T-score (for vertebral site, -2.9 [-3.6 to -1.9] in Group F', -2.2 [-2.9 to -1.2] in Group NF') and DXA T-score (-2.8 [-3.3 to -1.9] in Group F', -2.2 [-2.9 to -1.4] in Group NF') were statistically significant (p-value <0.001). Analogous results were obtained for femoral neck. Considering the T-score cut-off of -2.5, REMS identified Group F' patients with a sensitivity of 65.1% and specificity of 57.7% of (OR = 2.6, 95%CI: 1.77-3.76, p < 0.001), whereas DXA showed a sensitivity of 57.1% and a specificity of 56.3% (OR = 1.7, 95%CI: 1.20-2.51, p-value = 0.0032). For femoral neck, REMS sensitivity and specificity were 40.2% and 79.9%, respectively, with an OR of 2.81 (95%CI: 1.80-4.39, p < 0.001). DXA, instead, showed a sensitivity and specificity of 42.3% and 79.3%, respectively, with an OR of 2.68 (95%CI: 1.71-4.21, p < 0.001).

CONCLUSIONS

REMS T-score resulted an effective predictor for the risk of incident fragility fractures in a population-based sample of female subjects, representing a promising parameter to enhance osteoporosis diagnosis in the clinical routine.

Performance of FRAX in Predicting Fractures in US Postmenopausal Women with Varied Race and Genetic Profiles

BACKGROUND

Whether the Fracture Risk Assessment Tool (FRAX) performed differently in estimating the 10-year fracture probability in women of different genetic profiling and race remained unclear.

METHODS

The genomic data in the Women's Health Initiative (WHI) study was analyzed (n = 23,981). The genetic risk score (GRS) was calculated from 14 fracture-associated single nucleotide polymorphisms (SNPs) for each participant. FRAX without bone mineral density (BMD) was used to estimate fracture probability.

RESULTS

FRAX significantly overestimated the risk of major osteoporotic fracture (MOF) in the WHI study. The most significant overestimation was observed in women with low GRS (predicted/observed ratio (POR): 1.61, 95% CI: 1.45-1.79) specifically Asian women (POR: 3.5, 95% CI 2.48-4.81) and in African American women (POR: 2.59, 95% CI: 2.33-2.87). Compared to the low GRS group, the 10-year probability of MOF adjusted for the FRAX score was 21% and 30% higher in the median GRS group and high GRS group, respectively. Asian, African American, and Hispanic women respectively had a 78%, 76%, and 56% lower hazard than Caucasian women after the FRAX score was adjusted. The results were similar for hip fractures.

CONCLUSIONS

Our study suggested the FRAX performance varies significantly by both genetic profile and race in postmenopausal women.

Mapping theme trends and recognizing hot spots in postmenopausal osteoporosis research: a bibliometric analysis

Background

This study aimed to draw a series of scientific maps to quantitatively and qualitatively evaluate hot spots and trends in postmenopausal osteoporosis research using bibliometric analysis.

Methods

Scientific papers published on postmenopausal osteoporosis were extracted from the Web of Science Core Collection and PubMed database. Extracted information was analyzed quantitatively with bibliometric analysis by CiteSpace, the Online Analysis Platform of Literature Metrology and Bibliographic Item Co-Occurrence Matrix Builder (BICOMB). To explore the hot spots in this field, co-word biclustering analysis was conducted by gCLUTO based on the major MeSH terms/MeSH subheading terms-source literatures matrix.

Results

We identified that a total of 5,247 publications related to postmenopausal osteoporosis were published between 2013 and 2017. The overall trend decreased from 1,071 literatures in 2013 to 1,048 literatures in 2017. Osteoporosis International is the leading journal in the field of postmenopausal osteoporosis research, both in terms of impact factor score (3.819) and H-index value (157). The United States has retained a top position and has exerted a pivotal influence in this field. The University of California, San Francisco was identified as a leading institution for research collaboration, and Professors Reginster and Kanis have made great achievements in this area. Eight research hot spots were identified.

Conclusions

Our study found that in the past few years, the etiology and drug treatment of postmenopausal osteoporosis have been research hot spots. They provide a basis for the study of the pathogenesis of osteoporosis and guidelines for the drug treatment of osteoporosis.

Prediction of Low and Very Low Bone Mineral Density Among Adult Survivors of Childhood Cancer

PURPOSE

To develop and validate prediction models for low and very low bone mineral density (BMD) on the basis of clinical and treatment characteristics that identify adult survivors of childhood cancer who require screening by dual-energy x-ray absorptiometry.

PATIENTS AND METHODS

White survivors of childhood cancer (n = 2,032; median attained age, 29.3 years [range, 18.1 to 40.9 years]) enrolled in the St Jude Lifetime Cohort (SJLIFE; development) and survivors treated at the Erasmus Medical Center (validation) in the Netherlands (n = 403; median age, 24.2 years [range, 18.0 to 40.9 years]) were evaluated with dual-energy x-ray absorptiometry to determine lumbar spine BMD and total-body BMD. Low and very low BMD were defined as lumbar spine BMD and/or total-body BMD z scores of -1 or lower or -2 or lower, respectively. Multivariable logistic regression was used to build prediction models; performance was assessed using receiver operating characteristic curves. Diagnostic values were calculated at different probabilities.

RESULTS

Low BMD was present in 51% and 45% of SJLIFE and Dutch participants, respectively, and very low BMD was present in 20% and 10%, respectively. The model for low BMD included male sex (odds ratio [OR], 3.07), height (OR, 0.95), weight (OR, 0.98), attained age (OR, 0.97), current smoking status (OR, 1.48), and cranial irradiation (OR, 2.11). Areas under the curve were 0.72 (95% CI, 0.70 to 0.75) in the SJLIFE cohort and 0.69 (95% CI, 0.64 to 0.75) in the Dutch cohort. The sum of the sensitivity (69.0%) and specificity (64.0%) was maximal at the predicted probability of 50%. The model for very low BMD included male sex (OR, 3.28), height (OR, 0.95), weight (OR, 0.97), attained age (OR, 0.98), cranial irradiation (OR, 2.07), and abdominal irradiation (OR, 1.61), yielding areas under the curve of 0.76 (95% CI, 0.73 to 0.78; SJLIFE cohort) and 0.75 (95% CI, 0.67 to 0.83; Dutch cohort).

CONCLUSION

Validated prediction models for low and very low BMD, using easily measured patient and treatment characteristics, correctly identified BMD status in most white adult survivors through age 40 years.

Performance of predictive tools to identify individuals at risk of non-traumatic fracture: a systematic review, meta-analysis, and meta-regression

There is no consensus on which tool is the most accurate to assess fracture risk. The results of this systematic review suggest that QFracture, Fracture Risk Assessment Tool (FRAX) with BMD, and Garvan with BMD are the tools with the best discriminative ability. More studies assessing the comparative performance of current tools are needed.

INTRODUCTION

Many tools exist to assess fracture risk. This review aims to determine which tools have the best predictive accuracy to identify individuals at high risk of non-traumatic fracture.

METHODS

Studies assessing the accuracy of tools for prediction of fracture were searched in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Global Health. Studies were eligible if discrimination was assessed in a population independent of the derivation cohort. Meta-analyses and meta-regressions were performed on areas under the ROC curve (AUCs). Gender, mean age, age range, and study quality were used as adjustment variables.

RESULTS

We identified 53 validation studies assessing the discriminative ability of 14 tools. Given the small number of studies on some tools, only FRAX, Garvan, and QFracture were compared using meta-regression models. In the unadjusted analyses, QFracture had the best discriminative ability to predict hip fracture (AUC = 0.88). In the adjusted analysis, FRAX with BMD (AUC = 0.81) and Garvan with BMD (AUC = 0.79) had the highest AUCs. For prediction of major osteoporotic fracture, QFracture had the best discriminative ability (AUC = 0.77). For prediction of osteoporotic or any fracture, FRAX with BMD and Garvan with BMD had higher discriminative ability than their versions without BMD (FRAX: AUC = 0.72 vs 0.69, Garvan: AUC = 0.72 vs 0.65). A significant amount of heterogeneity was present in the analyses.

CONCLUSIONS

QFracture, FRAX with BMD, and Garvan with BMD have the highest discriminative performance for predicting fracture. Additional studies in which the performance of current tools is assessed in the same individuals may be performed to confirm this conclusion.

Administrative healthcare data applied to fracture risk assessment

Fracture risk scores generated from population-based administrative healthcare data showed comparable or better discrimination than the Fracture Risk Assessment Tool (FRAX) scores computed without bone mineral density for predicting incident major osteoporotic fracture. Administrative data may be useful to identify individuals at high fracture risk at the population level.

PURPOSE

To evaluate the discrimination of fracture risk scores defined using inputs available from administrative data for predicting incident major osteoporotic fracture (MOF) and hip fracture (HF) alone.

METHODS

Using the Manitoba Bone Mineral Density (BMD) Database (1997-2013), we identified 61,041 individuals aged 50 years or older with healthcare coverage following their first BMD test. We calculated two-modified FRAX)scores based on administrative data: FRAX-A and FRAX-A⁺. The FRAX-A modification used all FRAX inputs, except for BMD, body mass index, and parental HF, while the FRAX-A⁺ modification using all FRAX-A inputs plus a comorbidity score, number of hospitalizations in the 3 years prior to the BMD test, depression diagnosis, and dementia diagnosis. FRAX scores computed with BMD (i.e., FRAX [BMD]) and without BMD (i.e., FRAX [no-BMD]) were the comparators.

RESULTS

During a mean of 7 years of follow-up, we identified 5306 (8.7%) incident MOF and 1532 (2.5%) incident HF. The c-statistic for MOF associated with FRAX-A was lower than FRAX (BMD) (0.655 vs 0.675; P < 0.05) and comparable to FRAX (no-BMD) (0.654; P = 0.07). The c-statistic for MOF using FRAX-A⁺ (0.663) was lower than FRAX (BMD) but higher than FRAX (no-BMD) (both P < 0.05). For predicting incident HF, c-statistics associated with FRAX-A (0.762) and FRAX-A⁺ (0.767) were lower than FRAX (BMD) (0.789) and FRAX (no-BMD) (0.773; both P < 0.05).

CONCLUSIONS

FRAX-A and FRAX-A⁺ showed comparable or better discrimination than FRAX without BMD for predicting incident MOF, but slightly lower discrimination for HF alone.

Role of Bisphosphonate Therapy in Patients with Osteopenia: A Systemic Review

By contrast to clinical trials exploring osteoporosis, clinical trials specifically designed for the osteopenic population are limited. Thus, less clinical data are available regarding treatment benefits and cost-effectiveness of treating a patient population with a bone mass density in the osteopenic range (T-score between -1 and -2.5). In this article, we aimed to highlight this high-risk population with a low bone mass density (BMD) susceptible to high fracture risk by reviewing different national and international guidelines for treating osteopenia. The cost-effectiveness of the therapy for the above-mentioned patient population is also discussed. By reviewing different clinical trials, we have specifically highlighted the role of bisphosphonate therapy for fracture risk reduction and increment in bone mineral density (BMD) in patients with osteopenia.

The association between 10-year fracture risk by FRAX and osteoporotic fractures with disease activity in patients with rheumatoid arthritis

As rheumatoid arthritis (RA) is an independent risk factor for osteoporotic fractures, the severity of disease activity may correlate with fracture risk. Our objectives were to determine the prevalence of major osteoporotic and hip fractures in patients with RA and to identify the factors related to their 10-year probabilities. This study enrolled 232 patients with RA, aged 40-90 years, who participated in the Siriraj RA Cohort in 2016 and 2017. Demographic data, disease activity scores 28 (DAS28), and health assessment questionnaires (HAQ) were collected. All participants were evaluated for asymptomatic vertebral fractures by thoracolumbar spine radiography. The osteoporotic fracture risks were determined using the fracture risk assessment tool (FRAX). Most subjects were postmenopausal women in their sixth decade; the median disease duration was 12.95 years. Forty-six percent of patients had osteoporotic fractures, and most (87%) were vertebral fractures. Eighty-one patients had asymptomatic vertebral compression fractures. Of those, 57%, 25%, and 18% had low, moderate, and high 10-year probabilities of major osteoporotic fractures, respectively, while 51%, 34%, and 15% had low, moderate, and high 10-year probabilities of hip fractures, respectively. Factors significantly associated with the 10-year probabilities of major osteoporotic and hip fractures were disease duration (p 0.017, 0.009), menopause duration (p < 0.001 both), cumulative disease activity (DAS28; p 0.004, 0.029), and cumulative functional disability (HAQ; p < 0.001 both). Moderate to high 10-year probabilities of major osteoporotic and hip fractures are common in RA. Cumulative disease severity is a high risk for osteoporotic fractures.

What is the Fracture Risk in Patients at a Multidisciplinary Neuromuscular Clinic?

Many neuromuscular diseases (NMD) result in muscle weakness, immobility and greater fracture risk. The objective of this study is to determine the fracture risk of adult patients at a multidisciplinary NMD clinic. Fracture risk was calculated using the Fracture Risk Assessment Tool, the presence of osteoporosis was quantified using bone densitometry and contributing co-morbidities were screened through serum markers. Of the 36 patients studied, 47% were found to be of moderate and high fracture risk. Two thirds of these patients had not been previously screened or treated for osteoporosis. These findings suggest that NMD patients warrant routine screening for osteoporosis and early treatment to reduce fragility fracture.

Does bone mineral density improve the predictive accuracy of fracture risk assessment? A prospective cohort study in Northern Denmark

OBJECTIVE

To evaluate the added predictive accuracy of bone mineral density (BMD) to fracture risk assessment.

DESIGN

Prospective cohort study using data between 01 January 2010 and 31 December 2012.

SETTING

North Denmark Osteoporosis Clinic of referred patients presenting with at least one fracture risk factor to the referring doctor.

PARTICIPANTS

Patients aged 40-90 years; had BMD T-score recorded at the hip and not taking osteoporotic preventing drugs for more than 1 year prior to baseline.

MAIN OUTCOME MEASURES

Incident diagnoses of osteoporotic fractures (hip, spine, forearm, humerus and pelvis) were identified using the National Patient Registry of Denmark during 01 January 2012-01 January 2014. Cox regression was used to develop a fracture model based on predictors in the Fracture Risk Assessment Tool (FRAX®), with and without, binary and continuous BMD. Change in Harrell's C-Index and Reclassification tables were used to describe the added statistical value of BMD.

RESULTS

Adjusting for predictors included in FRAX®, patients with osteoporosis (T-score ≤-2.5) had 75% higher hazard of a fracture compared with patients with higher BMD (HR: 1.75 (95% CI 1.28 to 2.38)). Forty per cent lower hazard was found per unit increase in continuous BMD T-score (HR: 0.60 (95% CI 0.52 to 0.69)).Accuracy improved marginally, and Harrell's C-Index increased by 1.2% when adding continuous BMD (0.76 to 0.77). Reclassification tables showed continuous BMD shifted 529 patients into different risk categories; 292 of these were reclassified correctly (57%; 95% CI 55% to 64%). Adding binary BMD however no improvement: Harrell's C-Index decreased by 0.6%.

CONCLUSIONS

Continuous BMD marginally improves fracture risk assessment. Importantly, this was only found when using continuous BMD measurement for osteoporosis. It is suggested that future focus should be on evaluation of this risk factor using routinely collected data and on the development of more clinically relevant methodology to assess the added value of a new risk factor.

2018 update of French recommendations on the management of postmenopausal osteoporosis

OBJECTIVES

To update the 2012 recommendations on pharmacotherapy for postmenopausal osteoporosis, under the aegis of the Bone Task Force of the French Society for Rheumatology (SFR) and of the Osteoporosis Research and Information Group (GRIO), in collaboration with scientific societies (Collège national des généralistes enseignants, Collège national des gynécologues et obstétriciens français, Fédération nationale des collèges de gynécologie médicale, Groupe d'étude de la ménopause et du vieillissement hormonal, Société française de chirurgie orthopédique, Société française d'endocrinologie, and Société française de gériatrie et de gérontologie).

METHODS

Updated recommendations were developed by a task force whose members represented the medical specialties involved in the management of postmenopausal osteoporosis. The update was based on a literature review and developed using the method advocated by the French National Authority for Health (HAS).

DISCUSSION AND CONCLUSION

The updated recommendations place strong emphasis on the treatment of women with severe fractures, in whom the use of osteoporosis medications is recommended. All the available osteoporosis medications are suitable in patients with severe fractures; zoledronic acid deserves preference as the fist-line drug after a hip fracture. In patients with or without non-severe fractures, the decision to use osteoporosis medications is based on bone mineral density values and in challenging cases, on probabilities supplied by prediction tools such as FRAX^®. All osteoporosis medications are suitable; raloxifene should be reserved for patients at low risk for peripheral fractures. The fracture risk should be reevaluated every 2 to 3 years to decide on the best follow-up treatment. These updated recommendations discuss the selection of first-line osteoporosis medications and treatment sequences.

Fracture Risk Assessment With FRAX Using Real-World Data in a Population-Based Cohort From Israel

The predictive value of the World Health Organization's Fracture Risk Assessment Tool (FRAX) was evaluated using real-world community data. A population-based cohort of 141,320 women aged 50-90 years (median age, 58 years; interquartile range, 54-67) in 2004 was extracted from the central database of a large Israeli health-care services provider and insurer. Retrospective FRAX scores were calculated using computerized health records and compared with actual incidence of major osteoporotic fractures (MOFs) during the following 10 years. Fracture proportions of 6.9% for MOFs and 2.2% for hip fractures were expected, as opposed to 13.5% and 2.9% observed. The area under the receiver operating characteristic curve (AUC) of FRAX scores calculated without the inclusion of bone mineral density (BMD) data was 0.65 (95% confidence interval: 0.65, 0.66) for MOF and 0.82 (95% confidence interval: 0.81, 0.82) for hip fracture. A total of 16,578 subjects had BMD data at the index date, and their risk estimates based solely on BMD exhibited lower predictive performance for both MOFs (AUC = 0.62 vs. 0.65; P = 0.003) and hip fractures (AUC = 0.78 vs. 0.84; P < 0.001) as compared with FRAX. FRAX scores based on electronic health records provided reasonable discrimination despite some underestimation of the absolute risk of nonhip fractures. Integration of FRAX with routine clinical systems could increase implementation in daily practice and improve risk detection, especially for patients without BMD data.

Adjusting FRAX® on TBS for identification of subjects at high risk of fractures

The objective of this study was to compare the proportion of patients at high fracture risk according to FRAX® and FRAX® adjusted on TBS in patients hospitalized for a non vertebral fractures. Patients were selected from a Fracture Liaison Service FLS): clinical risk factors, bone mineral density (BMD) and TBS were assessed at the time of the fracture. Without considering the current fracture, we calculated FRAX® and FRAX® adjusted on TBS (TBS-FRAX®), and compared the proportion of patients with a high risk for major osteoporotic fracture (MOF)>20% according to FRAX® and TBS-FRAX®, and the proportion of subjects who should be treated according to current guidelines. Four hundred and thirteen patients were included for a non vertebral fracture (84.5% women, mean age of 73.9±11.7years), Two hundred and eight patients (50.4%) had osteoporosis (T≤-2.5 at least one site) and the mean value of TBS was 1.206 (±0.111). The proportion of patients with a risk of MOF≥20% before the fracture was similar with FRAX® and TBS-FRAX® (24.7% vs 25.4%). The proportion of patients identified with a risk of MOF above the threshold value of therapeutic intervention was higher using TBS-FRAX® than FRAX® for the age categories of 60-70years (38.3% vs 30.9%, p=0.01) and 70-80years (31.2% vs. 26.6%, p=0.04). This study showed that the proportion of patients at high risk of fracture is similar using FRAX® and FRAX® adjusted on TBS in patients hospitalized for a non vertebral fracture in a FLS.

Non-surgical management of acute osteoporotic vertebral compression fracture: A review

Osteoporosis is a major public health problem. Last decade has seen rise in osteoporotic vertebral fractures. Pragmatic management of osteoporotic VCF is challenging to the surgeons. In clinical settings, the situation becomes more complex when it comes to managing painful osteoporotic vertebral compression fractures (VCFs) due to various co-morbid factors that may limit aggressive interventions. Patients with Osteoporotic vertebral fractures are often characterized by general/relative immobility and physical frailty. Osteoporotic VCF not only affects the quality of life (e.g. pain) but also decreases the lifespan of the individual. The present review critically evaluates the currently prevailing non-surgical management modalities (conservative) offered in acute symptomatic osteoporotic VCFs that occur either within (0-5 days) of any incident event or present with the onset of symptoms such as pain.

Relationship between the FRAX® score and falls in community-dwelling middle-aged and elderly people

OBJECTIVES

Falls is a risk factor for fracture. The FRAX^® predicts fractures. Whether the FRAX^® is associated with fall in both gender is inconclusive. The aim of our study is to evaluate the association between FRAX scores and falls.

METHODS

The cross-sectional study set from 2009 to 2010 included 1200 community-dwelling people who were systematically sampled in central Taiwan. The 1200 participants (men: 524; women: 676; ≥40 years old) completed questionnaires about socioeconomic status; lifestyle; medical and fall history were completed. FRAX scores with and without bone mineral density (BMD) were calculated by using the Taiwan calculator.

RESULTS

A total of 19.8% participants fell down. Binary regression models showed that diabetes mellitus history (OR: 1.61; 95% CI: 1.03-2.52), the FRAX without BMD in a continuous major score (OR: 1.06; 95% CI: 1.03-1.09), continuous hip score (OR: 1.11; 95% CI: 1.05-1.16), categorical major score ≥ 10% (OR: 1.81; 95% CI: 1.25-2.61), and categorical hip score ≥ 3% (OR: 1.80; 95% CI: 1.30-2.50) were independent risk factors for falls. FRAX with BMD in a continuous major score (OR: 1.04; 95% CI: 1.02-1.06), continuous hip score (OR: 1.06; 95% CI: 1.02-1.09), categorical major score ≥ 10% (OR: 1.52; 95% CI: 1.09-2.12), and categorical hip score ≥ 3% (OR: 1.53; 95% CI: 1.13-2.09) were also independent risk factors.

CONCLUSIONS

We concluded that FRAX^® scores with and without BMD were unanimously correlated with falls in community-dwelling middle-aged and elderly males and females.

In Vivo Characterization of Cortical Bone Using Guided Waves Measured by Axial Transmission

Cortical bone loss is not fully assessed by the current X-ray methods, and there is an unmet need in identifying women at risk of osteoporotic fracture, who should receive a treatment. The last decade has seen the emergence of the ultrasound (US) axial transmission (AT) techniques to assess a cortical bone. Recent AT techniques exploit the multimode waveguide response of the long bones such as the radius. A recent ex vivo study by our group evidenced that a multimode AT approach can yield simultaneous estimates of cortical thickness (Ct.Th) and stiffness. The aim of this paper is to move one step forward to evaluate the feasibility of measuring multimode guided waves (GW) in vivo and to infer from it cortical thickness. Measurements were taken on the forearm of 14 healthy subjects with the goal to test the accuracy of the estimated thickness using the bidirectional AT method implemented on a dedicated 1-MHz linear US array. This setup allows determining in vivo the dispersion curves of GW transmitted in the cortical layer of the radius. An inverse procedure based on the comparison between the measured and modeled dispersion curves predicted by a 2-D transverse isotropic free plate waveguide model allowed an estimation of cortical thickness, despite the presence of soft tissue. The Ct.Th values were validated by comparison with the site-matched estimates derived from X-ray high-resolution peripheral quantitative computed tomography. Results showed a significant correlation between both measurements ( r² = 0.7 , , and [Formula: see text] mm). This pilot study demonstrates the potential of bidirectional AT for the in vivo assessment of cortical thickness, a bone strength-related factor.

[Post-menopausal osteoporosis: Up-to-date]

Patients with a high risk of fragility fractures, and those with recent fractures, must receive the highest priority for anti-osteoporotic treatment, because of the consequences of some of these fractures (hip, vertebrae, pelvis, humerus). Both non pharmacological and pharmacological treatments must be used. The duration of the treatment is based on the assessment of fracture risk.

The impact of comorbidities on the physical function in patients with rheumatoid arthritis

OBJECTIVES

To investigate the association of comorbidities with mobility limitation and functional disability in patients with rheumatoid arthritis and to identify which comorbidity indicator is the most appropriate to determine this association.

METHODS

Sixty rheumatoid arthritis patients were enrolled in a cross-sectional study for a period of 11 months. Comorbidities were assessed using three indicators: (i) the total number of comorbidities; (ii) the Charlson comorbidity index; and (iii) the functional comorbidity index. Disease activity was assessed using the Disease Activity Score 28. Functional capacity was measured using the Health Assessment Questionnaire, and mobility was measured using Timed Up and Go Test and Five-Times-Sit-to-Stand Test. Statistical analysis was performed using a stepwise log-linear multiple regression with a significance level of 5%.

RESULTS

In the final model, only comorbidity was associated with mobility limitation. The functional comorbidity index score explained 19.1% of the variability of the Five-Times-Sit-to-Stand Test (coefficient of determination [R(2)]=0.191) and 19.5% of the Timed Up and Go Test variability (R(2)=0.195). With regard to functional disability, the associated factors were comorbidity and disease activity, which together explained 32.9% of the variability of the Health Assessment Questionnaire score (adjusted R(2)=0.329).

CONCLUSION

Comorbidities were associated with mobility limitation and functional disability in rheumatoid arthritis patients. The functional comorbidity index proved to be an appropriate comorbidity indicator to determine this association.

The discriminative ability of FRAX, the WHO algorithm, to identify women with prevalent asymptomatic vertebral fractures: a cross-sectional study

BACKGROUND

A Moroccan model for the FRAX tool to determine the absolute risk of osteoporotic fracture at 10 years has been established recently. The study aimed to assess the discriminative capacity of FRAX in identifying women with prevalent asymptomatic vertebral fractures (VFs).

METHODS

We enrolled in this cross-sectional study 908 post-menopausal women with a mean age of 60.9 years ± 7.7 (50 to 91) with no prior known diagnosis of osteoporosis. Subjects were recruited from asymptomatic women selected from the general population. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genantsemiquantitative (SQ) approach and morphometry. We calculated the absolute risk of major fracture and hip fracture with and without bone mineral density (BMD)using the FRAX website.The overall discriminative value of the different risk scores was assessed by calculating the areas under the ROC curve (AUC).

RESULTS

VFA images showed that 179 of the participants (19.7%) had at least one grade 2/3 VF. The group of women with VFs had a statistically significant higher FRAX scores for major and hip fractures with and without BMD, and lower weight, height, and lumbar spine and hip BMD and T-scores than those without a VFA-identified VF. The AUC ROC of FRAX for major fracture without BMD was 0.757 (CI 95%; 0.718-0.797) and 0.736 (CI 95%; 0.695-0.777) with BMD, being 0.756 (CI 95%; 0.716-0.796) and 0.747 (CI 95%; 0.709-0.785), respectively for FRAX hip fracture without and with BMD. The AUC ROC of lumbar spine T-score and femoral neck T-score were 0.660 (CI 95%; 0.611-0.708) and 0.707 (CI 95%; 0.664-0.751) respectively.

CONCLUSION

In asymptomatic post-menopausal women, the FRAX risk for major fracture without BMD had a better discriminative capacity in identifying the women with prevalent VFs than lumbar spine and femoral neck T-scores suggesting its usefulness in identifying women in whom VFA could be indicated.