Epidemiology of osteoporotic fractures in Brazil: what we have and what we need

Geographic variation in bone mineral density and prevalent fractures in the Canadian longitudinal study on aging

Awareness of the prevalence of osteoporosis and fractures across jurisdictions can guide the development of local preventive programs and healthcare policies. We observed geographical variations in total hip bone mineral density and in the prevalence of major osteoporotic fractures across Canadian provinces, which persisted after adjusting for important covariates.

PURPOSE

We aimed to describe sex-specific total hip bone mineral density (aBMD) and prevalent major osteoporotic fractures (MOF) variation between Canadian provinces.

METHODS

We used baseline data from 21,227 Canadians (10,716 women, 10,511 men) aged 50-85 years in the Canadian Longitudinal Study on Aging (CLSA; baseline: 2012-2015). Linear and logistic regression models were used to examine associations between province of residence and total hip aBMD and self-reported MOF, stratified by sex. CLSA sampling weights were used to generate the prevalence and regression estimates.

RESULTS

The mean (SD) age of participants was 63.9 (9.1) years. The mean body mass index (kg/m2) was lowest in British Columbia (27.4 [5.0]) and highest in Newfoundland and Labrador (28.8 [5.3]). Women and men from British Columbia had the lowest mean total hip aBMD and the lowest prevalence of MOF. Alberta had the highest proportion of participants reporting recent falls (12.0%), and Manitoba (8.4%) the fewest (p-value=0.002). Linear regression analyses demonstrated significant differences in total hip aBMD: women and men from British Columbia and Alberta, and women from Manitoba and Nova Scotia had lower adjusted total hip aBMD than Ontario (p-values<0.02). Adjusted odds ratios (95% confidence intervals, CI) for prevalent MOF were significantly lower in women from British Columbia (0.47 [95% CI: 0.32; 0.69]) and Quebec (0.68 [95% CI: 0.48; 0.97]) and in men from British Columbia (0.40 [95% CI:0.22; 0.71]) compared to Ontario (p-values<0.03). Results were similar when adjusting for physical performance measures and when restricting the analyses to participants who reported White race/ethnicity.

CONCLUSION

Geographical variations in total hip aBMD and in the prevalence of MOF between provinces persisted after adjusting for important covariates which suggests an association with unmeasured individual and environmental factors.

Serum 25 hydroxyvitamin D concentrations in individuals over 80 years old and their correlations with musculoskeletal and health parameters

PURPOSE

The present study aims to evaluate the serum concentrations of 25 hydroxyvitamin D[25(OH)D] in individuals aged ≥80 years, independent, free-living in Sao Paulo, Brazil (Lat 23.5 ^oS), and to investigate their associations with musculoskeletal system, physical performance and health markers.

METHOD

This cross-sectional study included 212 community dwellers aged ≥80 years and evaluated serum 25(OH)D, PTH, calcium, albumin, phosphorus, creatinine, bone markers, and bone mineral density. Physical performance was evaluated with stationary march, Flamingo, and functional reach tests, questionnaires to assess falls and fractures in the previous year, energy expenditure (MET), and Charlson index. Physical activity was evaluated with the International Physical Activity Questionnaire.

RESULTS

Vitamin D deficiency (<20 ng/mL) was observed in 56% and severe vitamin D deficiency (<10 ng/mL) in 13% of those individuals. Serum concentrations of 25(OH)D were significantly and positively associated with BMD total hip (p = 0.001), femoral neck (p = 0.011) and 33% radius (p = 0.046) BMDs, MET (p = 0.03) and functional reach test (p = 0.037) and negatively with age (p = 0.021), PTH (p = 0.004) and osteoporosis diagnosis (p = 0.012). Long-lived individuals with 25(OH)D ≥ 20 ng/mL had higher total hip and femoral neck BMDs (p = 0.012 and p = 0.014, respectively) and lower PTH (p = 0.030). In multiple linear regression analysis, age and osteoporosis diagnosis remained negatively associated with 25(OH)D levels (p = 0.021 and p = 0.001, respectively), while corrected calcium and cholecalciferol use remained positively associated (p = 0.001 and p = 0.024, respectively).

CONCLUSION

We observed high vitamin D inadequacy prevalence in those Brazilian community dwellers' oldest old. Serum concentrations of 25(OH)D were positively associated with bone mass and dynamic balance, and negatively with PTH and osteoporosis diagnosis. Additionally, 25(OH)D ≥ 20 ng/mL was associated with better bone mass and lower PTH levels.

O impacto das fraturas do quadril no SUS 2008 - 2017: O papel do ortopedista

Objective The present study intends to describe the profile of hospitalization and ambulatory rehabilitation of patients ≥ 50 years old due to hip fracture in the Brazilian Public Health System (SUS, in the Portuguese acronym).

Methods This is a cross-sectional study of patients hospitalized due to hip fracture in the SUS between 2008 and 2017. Data included 441,787 hip fracture-related hospitalizations from the hospitalization database of the department of informatics of the Brazilian Unified Health System (SIH/DATASUS, in the Portuguese acronym), and data of patients who underwent rehabilitation from the ambulatory database of the department of informatics of the Brazilian Unified Health System (SIA/DATASUS, in the Portuguese acronym.).

Results Most of hip fracture-related hospitalizations (83.5%) happen to people ≥ 50 years old, with an average annual growth of 5.6% in hip fracture-related hospitalizations. The costs for the government have been growing in the same proportion and reached almost BRL 130 million in 2017, although with a 13.6% decrease in average cost per hospitalization. Besides the financial impact, hip fractures result in an in-hospital mortality rate around 5.0% in patients aged ≥ 50 years old. In addition, the percentage of patients that have undergone hip fracture-related rehabilitation increased from 2008 (14.0%) to 2012 (40.0%), and remained stable after that.

Conclusions The progressive increase in the incidence of hip fractures shows the financial and social impact, and the need for immediate actions to prevent this rising trend. Hip fractures are a risk for secondary fractures, the prevention is crucial, and the orthopedist plays a central role in this process.

Incidence of fractures in women in the post-menopause: a cohort study in primary care in southern Brazil

The incidences of total fracture, major fracture, and hip fractures in primary care in Southern Brazil were 22.3, 15.0, and 3.3 per 1000 person/year. The FRAX algorithm showed an adequate discriminatory capacity for the identification of these fractures.

OBEJECTIVE

Few studies are evaluating the incidence of fractures in Latin America and Brazil. This study aimed to estimate the incidence of bone fractures in postmenopausal women seen in primary care and evaluate the FRAX algorithm's performance in these women.

METHODS

A cohort study was carried out in the municipality of Santa Maria, Southern Brazil. Postmenopausal women aged 55 years and over who attended primary health care were included. The recruitment period was from March 1 to August 31, 2013, and the participants were followed for 5 years. The fracture risk was calculated using the FRAX algorithm. The reported incident fractures were confirmed by imaging studies or surgical reports.

RESULTS

Of the 1057 women recruited for the study, 854 were followed. They contributed to 2732 person/year. The mean follow-up time was 3.2 years (SD 1.05). The incidences of total fractures, major fractures, and hip fractures were 22.3, 15.0, and 3.3 per 1000 person/year. The most frequent fracture sites were the wrist, shoulder, and ribs. The fracture predictors were rheumatoid arthritis, previous fracture, and the use of glucocorticoids. The discriminatory capacity of incident fractures calculated by FRAX without the inclusion of BMD was AUC 0.730 (95% CI 0.570, 0.890) for hip fracture and AUC 0.691 (95% CI 0.598, 0.784) for major fractures.

CONCLUSION

The FRAX algorithm showed an adequate discriminatory capacity to identify incident fractures in primary care in our study. The incidence of fractures found in our study appears to be lower than that reported in North America and Europe.

EVALUATION OF POST-SURGICAL MANAGEMENT OF FRAGILITY FRACTURES

OBJECTIVE

To evaluate the conduct of Brazilian orthopedists regarding preventive treatment after fragility fracture surgery.

METHODS

A questionnaire was applied to Brazilian orthopedists. Statistical analyses were performed using the SPSS 16.0 program.

RESULTS

257 participants were analyzed. Most participants, 90.7% (n = 233), reported that they cared for patients with fractures and 62.3% (n = 160) treated them. The most indicated treatments were vitamin D (22.6%; n = 134) and calcium supplementation (21.4%; n = 127). According to the experience of the physicians - experienced (n = 184) and residents (n = 73) - fragility fractures were more common in the routine of residents (98.6%; n = 72) than experienced physicians (87.5%; n = 161), p = 0.0115. While treatment conduction was more reported by experienced physicians (63.6%; n = 117) than residents (58.9%; n = 43), p = 0.004. More experienced orthopedists (21.4%; n = 97) indicated treatment with bisphosphates than residents (14.2%; n = 20), p = 0.0266.

CONCLUSION

Although most professionals prescribe treatment after fragility fracture surgery, about 40% of professionals still do not treat it, with differences in relation to experience. In this sense, we reinforce the importance of secondary prevention in the management of fragility fractures. Level of Evidence II, Prospective comparative study.

Epidemiology of low-energy fracture in Chinese postmenopausal women: changing trend of incidence since menopause and associated risk factors, a national population-based survey

OBJECTIVE

The aim of the study was to report the incidence of low-energy fracture since menopause in postmenopausal women ≤70 years and to explore associated risk factors METHODS:: This was a part of the Chinese National Fracture Survey (CNFS), which was carried out in eight provinces of China mainland between January and May 2015. Data on 68,783 postmenopausal women ≤70 years were extracted from the CNFS database for calculations and analyses.

RESULTS

A total of 309 women were confirmed to have low-energy fractures in 2014, indicating the incidence of 449.2 (95% CI, 399.3-499.2) per 100,000 women. There were two obvious peaks of fracture incidence at the 4th year and the 9th year since menopause. From the 10th year on, the fracture incidence rate presented the relatively steady trends over years, only with slight interannual fluctuation. After adjustment for confounding variables, advanced age, higher latitude, milk intake ≥1/d, residence ≥2nd floor without elevator, alcohol consumption, sleep duration <7 h/d, history of past fracture, and more births were identified as significant risk factors. Supplementation of calcium or vitamin D or both was associated with 44% of fracture reduction (OR, 0.56; 95% CI, 0.37-0.84).

CONCLUSIONS

These data on low-energy fractures in postmenopausal women provided an updated clinical evidence base for better national healthcare planning and preventive efforts in China.

An In Silico Model for the Prediction of Changes in Mineral Density in Cortical Bone Remodeling

An in silico model for the estimation of volumetric bone mineral density (vBMD) changes at a cortical bone site subjected to mechanobiological bone remodeling is proposed in this manuscript. Mechanisms of cell differentiation, receptor-ligand binding, mechanical signaling, and resorption or deposition of bone matrix were considered, therefore providing a comprehensive description of mechanobiological bone remodeling in the bone microenvironment and enabling the analysis of temporal evolution of disease or therapy scenarios. The proposed model is composed by five modules, namely, bone cells populations, mechanobiology, volume fractions and porosity, mineral density, and structural stiffness. The model is an extension of other models found in the literature because equations for the obtaining of cortical vBMD and the binding of parathyroid hormone (PTH) to parathyroid hormone 1 receptor are included. The proposed model showed a satisfactory agreement with the solutions of other in silico models found in the literature. Simulations of walking and running exercise routines were performed for the evaluation of model capability regarding the control of the numerical error and prediction of vBMD. The computational method used to solve the case study controlled the relative numerical error by less than 1 × 10-7 for approximately 1.7 × 106 time steps. The predicted values correlate with the concept of increasing BMD by vigorous physical activity; however, they contrast with the specific effect of physical activities on cortical vBMD.

Epidemiology of low-energy wrist, hip, and spine fractures in Chinese populations 50 years or older: A national population-based survey

The aim of the study was to investigate the incidence of low-energy fracture of wrist, hip, and spine and the related risk factors in Chinese populations 50 years or older.This study was a part of the Chinese National Fracture Survey (CNFS) carried out in 8 Chinese provinces in 2015. Data on 154,099 Chinese men and women 50 years or older were extracted from the CNFS database for calculations and analyses. Low-energy fracture was defined as fracture caused by slip, trip, or falls from standing height.A total of 247 patients sustained low-energy fractures in 2014, indicating the incidence rate was 160.3/100,000 person-years, with 120.0 [95% confidence interval (CI), 95.5-144.5] and 213.1(95% CI, 180.7-245.6)/100,000 person-years in men and women, respectively. In men, advanced age, alcohol consumption, residence at second floor or above without elevator, sleep duration <7 h/day, and history of past fracture were identified to be significant risk factors for low-energy fractures. In women, advanced age, living in east region, higher latitude zone (40°N -49.9°N), alcohol consumption, more births, sleep duration <7 h/day, and history of past fracture were identified as significant risk factors. Supplementation of calcium or vitamin D or both was identified to be associated with reduced risk of fracture in women (odds ratio, 0.38; 95% CI, 0.20-0.75), but not in men.These epidemiologic data on low-energy fractures provided updated clinical evidence base for national healthcare planning and preventive efforts in China. Corresponding interventions such as decreasing alcohol consumption and sleep improvement should clearly be implemented. For women, especially those with more births and past history of fracture, routine screening of osteoporosis, and intensive nourishment since menopause should be advocated.

Unhealthy lifestyles are associated with the increased risk of low-energy fracture in Chinese men ≥ 50 years, a population-based survey

PURPOSE

This study aims to investigate the incidence of low-energy fractures in men aged 50 years and older in China and to explore associated risk factors.

METHODS

All the relevant data were available from the China National Fracture Survey (CNFS), which was a cross-sectional survey carried out in eight Chinese provinces (municipalities) between January and May 2015.

RESULTS

Through 2014, 76,687 men above 50 years participated in this study and 223 participants had low-energy fractures, indicating the incidence rate 290.8 (95%CI, 252.7-328.9)/100,000 men. Over 80% of the fractures occurred at home and on the common road. The fracture incidence rate presented a significant rising trend with advanced age (p = 0.039). Current smoking, alcohol overconsumption, insufficient sleep duration, and history of past fracture were identified as significant risk factors associated with low-energy fracture (p < 0.05).

CONCLUSIONS

These results will assist the decisions regarding allocation of healthcare provision to populations of greatest need and aid the design and implementation of strategies to reduce fracture incidence. Accordingly, individuals should be encouraged to reduce alcohol consumption, immediately quit smoking, and get sufficient sleep, especially in those with a history of past fracture. In addition, primary preventives especially home prevention should be emphasized.

Nutrition and Inflammation Influence 1-Year Mortality of Surgically Treated Elderly Intertrochanteric Fractures: A Prospective International Multicenter Case Series

Introduction:

Hip fracture is a common and devastating event in older adults causing increased dependence, comorbidity, and mortality. Since new surgical techniques have not significantly improved the mortality rate, a better understanding of patient risk factors could improve the treatment algorithm and outcomes. This prospective study aimed to document the 1-year survival rate of patients with intertrochanteric fracture treated surgically in Latin America and to investigate risk factors associated with 1-year mortality.

Patients and Methods:

Between January 2013 and March 2015, 199 patients were prospectively enrolled. Inclusion criteria were aged 60 years or older, isolated intertrochanteric fracture (AO/OTA 31-A), and time to surgery within 10 days after injury. The follow-up period was 1 year. The association between mortality and patient demographics, comorbidity, surgical details, and preoperative laboratory parameters was assessed using log-rank tests.

Results:

Twenty patients died by 365 days after surgery (including 5 that died within 30 days of surgery) resulting in a 1-year survival rate of 89.8% (95% confidence interval = 84.6-93.3). The 1-year mortality was significantly associated with age (≥85 years old, P = .032), existing comorbidity (P = .002), preinjury mobility level (P = .026), mental state (Mini-Mental State Examination > 23, P = .040), low preoperative plasma albumin level (P = .007), and high preoperative blood C-reactive protein level (CRP; P = .012). At the 1-year follow-up, patients on average did not regain their preinjury hip function and mobility, although the self-assessed quality of life was equal or better than before the injury.

Discussion:

As a prospective study, the current patient population had clear inclusion and exclusion criteria and was relatively homogeneous. The resulting associations between 1-year postoperative mortality and preoperative hypoalbuminemia and preoperative elevated CRP level are therefore especially notable. Previously identified risk factors such as male gender and time to surgery showed no significant association with 1-year mortality—the overall favorable condition of the current population or the lack of statistical power maybe responsible for this observation.

Conclusion:

The current results showed that under the condition of optimal surgical treatment and low surgery-related complication, preinjury health status as indicated by the blood level of albumin and CRP has a direct and significant impact on 1-year mortality rate.

Development of an app as a tool to support research and the prevention of osteoporosis

Abstract Objective: to develop an app for the investigation and prevention of osteoporosis for use by health professionals. Method: the development of the app was performed in six steps: definition of the target audience; survey of validated osteoporosis risk assessment tools in Brazil; programming of the app through the progressive web; selection of data for the preparation of sections of the evaluation form and clinical recommendations; automated auditing and evaluation of the app by health professionals. Results: three screens were prepared for the app. These were based on the data extracted using the Osteorisk, Sapori and Frax tools for sociodemographic data (age, gender, weight, height and ethnicity), health (use of glucocorticoids, hormone replacement therapy, arthritis rheumatoid arthritis, secondary osteoporosis, previous low impact fractures, parents with a history of hip fractures) and health related behaviors (physical activity, alcohol intake and smoking). The appl followed the design pattern and functionalities of the osteoporosis adviser tool (OPAD). Regarding guidelines relating to clinical recommendations, the guidelines on osteoporosis and fall prevention in the elderly of the Ministry of Health and the Brazilian Society of Geriatrics and Gerontology, respectively, were taken as a basis. Conclusion: the app allows the early identification of patients presenting risk factors for osteoporosis and, based on these results, provides guidance on the preventive measures to be adopted, aiming at reducing complications resulting from fractures, hospitalizations, disabilities and deaths.

FRAX Tool in Brazil: an integrative literature review following validation

Abstract The present article is an integrative review the objective of which was to assess research carried out with the FRAX tool in Brazil following its validation, and describe the conclusions drawn. Two databases were used to select the articles (the Capes Portal and the Virtual Health Library), and the sample of this review was the only four articles published in Brazil relating to the FRAX tool following its validation in May 2013. After analyzing the articles, the results demonstrated that despite some limitations the FRAX Tool can be used to reduce the prevalence of fractures due to its simplicity of use, with an emphasis on prediction and orientation, allowing early and safe therapeutic decision-making.

Osteoporosis and autophagy: What is the relationship?

Autophagy is a survival pathway wherein non-functional proteins and organelles are degraded in lysosomes for recycling and energy production. Therefore, autophagy is fundamental for the maintenance of cell viability, acting as a quality control process that prevents the accumulation of unnecessary structures and oxidative stress. Increasing evidence has shown that autophagy dysfunction is related to several pathologies including neurodegenerative diseases and cancer. Moreover, recent studies have shown that autophagy plays an important role for the maintenance of bone homeostasis. For instance, in vitro and animal and human studies indicate that autophagy dysfunction in bone cells is associated with the onset of bone diseases such as osteoporosis. This review had the purpose of discussing the issue to confirm whether a relationship between autophagy dysfunction and osteoporosis exits.

Association between body mass index and osteoporosis in women from northwestern Rio Grande do Sul

OBJECTIVE

To investigate the association between body mass index (BMI) and bone mineral density (BMD) in postmenopausal women.

METHODS

Observational study with postmenopausal women who underwent bone densitometry in Palmeira das Missões - RS. Sociodemographic data, risk for osteoporosis and food intake were assessed through a specific form. BMI was calculated according to WHO criteria. The assessment of BMD was performed by dual-energy X-ray absorptiometry (DXA) and classified according to WHO. Statistical analysis was performed using prevalence ratios (PR) and their respective 95% confidence intervals for the factors studied. Variables associated with p<0.20 with the different outcomes (osteopenia and osteoporosis) were included in a Poisson regression model with robust variance to adjust for potential confounding factors. A 5% significance level was considered.

RESULTS

393 postmenopausal women with a mean age of 59.6±8.2 years participated. After the adjustments, the normal weight women had 1.2 times the prevalence of osteopenia of obese women (PR=1.2; CI 95% 1.3-1.5). Considering osteoporosis, the PR of euthophic women was twice the PR of obese women (PR=2; CI 95% 1.4-2.9) and was 1.7 times greater for overweight group compared to obese category (PR=1.7; CI 95% 1.2-2.5).

CONCLUSION

Obese women had lower prevalence of osteopenia compared with normal weight subjects and also with lower prevalence of osteoporosis as compared to normal- and overweight women.

Multifactorial assessment of the risk of falls in low bone density older women

Abstract Introduction: Identifying effective assessment instruments for predicting falls, specifically in older women with low bone mineral density (BMD) that are more susceptible to fractures remains a challenge. Objective: To evaluate risk factors for falls at baseline, to identify the falls occurrence over six months of follow-up and to investigate the predictive validity of the Quickscreen Clinical Falls Risk Assessment for predicting multiple falls among low BMD older women. Methods: A methodological study with 110 older women with diagnosis of osteoporosis or osteopenia (70.26 ± 6.24 years). The presence of two or more of the eight risk factors assessed by the QuickScreen characterized the risk of falling (baseline) and monthly phone calls identified the occurrence of falls during the six months of follow-up. Results: The most prevalent falls risk factors were self-reported previous falls, polypharmacy and impairment in shifting weight and lateral instability. Most of the older women (67.3%) had two or more risk factors, 24.5% reported a single fall and 13.6% reported multiple falls over the six months. The QuickScreen (cutoff ≥ 2 risk factors) showed good sensitivity (73.3%) and high negative predictive value (88.89%) for predicting multiple falls among low BMD older women. Conclusions: The results indicated a high frequency of falls among low BMD older women. Additionally, the results highlighted that the QuickScreen instrument was able to predict multiple falls in the six months of follow-up among these older women.

Analysis of total calorie, calcium and protein intake and relationship with bone mineral density in postmenopausal women

Abstract Introduction: the adequate intake of nutrients involved in bone metabolism can prevent and even reduce the risk of osteoporosis. Objective: verify the intake of total calories, protein and calcium in women diagnosed with osteopenia and osteoporosis after menopause. Method: a study of 25 women diagnosed with osteopenia (n=17) or osteoporosis (n=8) in the postmenopausal period, who were members of the Prática de Exercícios Físicos na Osteoporose (Practice of Physical Exercise Against Osteoporosis) (PEFO) study group of the Universidade Tecnológica Federal do Paraná (the Federal Technology University of Paraná) (UTFPR). The study was divided into two data collection phases: assessment of body composition and bone mineral density by Dual-energy X-ray Absorptiometry (DXA) and the recording of food consumption over the previous 72 hours by means of a structured interview. Results: there was a difference between the reference values and the average values found for caloric, protein and calcium intake. There were higher values for protein, while calcium intake was low. The osteoporosis group (mean 59.24+80.07, p<0.05) ingested significantly more protein than the osteopenia group (mean 15.14+16.53, p<0.05). The results showed a significant negative correlation between protein intake and hip BMD (r=-0.416, p<0.05). Conclusion: adequate intake of protein should be recognized as a protective factor for osteoporosis and considered by nutritionists, as well as being widely featured in public health campaigns.

Effect of three months of periodized hydrogymnastics exercise program on urinary concentration of deoxypyridinoline in older women

OBJECTIVE

To determine the effect of three months of periodized hydrogymnastics exercise program on urinary concentration of deoxypyridinoline in older women.

SUBJECTS AND METHODS

Twenty-six subjects were randomly assigned in two, intervention group (n = 16) and control group (n = 10). The intervention group followed 12-week of periodized hydrogymnastics training program five times a week, 50 minutes of water exercise with work heart rate reserve of 40-50% (1-6th week) increasing the load to 50-60% (7-12th week); the control group was not involved in exercise and remained sedentary. The urinary concentration of deoxypyridinoline was evaluated by high resolution liquid chromatography using the reactive immulite pyrilinks-D siemens medical solutions, pretest at the baseline and at the end post-test of the 12-week of water-exercise. As statistical analyses mixed 2 x 2 ANOVA was used, also percentage changes (Δ %) was calculated.

RESULTS

The results did not show significant improvement (p < 0.05) comparing the interaction intergroup and the measurements of urinary concentration of deoxypyridinoline (p = 0.504), percentage change (Δ %) showed positive improvements in the experimental group of -13.7 (nM/mMcreatine) in comparison with -7.1 (nM/mMcreatine) from the control group.

CONCLUSION

The present study involves periodization increasing the load heart rate reserve of hydrogymnastics exercise in order to produce grater adaptations, but the results showed than is not possible to infer that hydrogymnastics is effective in increase urinary concentration of deoxypyridinoline in older women, will be appropriated in the future more studies to better clarify the possibilities of improvements between hydrogymnastics and urinary concentration of deoxypyridinoline.

An overview on the treatment of postmenopausal osteoporosis

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

Descriptive epidemiology of traumatic injuries in 18890 adults: a 5-year-study in a tertiary trauma center in iran

Background:

Basic epidemiological data can provide estimates when discussing disease burden and in the planning and provision of healthcare strategies. There is little quantitative information in the literature regarding prevalence of traumatic injuries from developing countries.

Objectives:

The aim of the current preliminary study was to reveal the prevalence and age and gender distribution of various traumatic injuries in a tertiary referral orthopedic hospital in Iran.

Patients and Methods:

In a prospective descriptive study, all traumatic injured patients attending the Orthopedic Trauma Unit of our center in a five year period were included. Demographic details, the cause of injury, injury classification and treatment were recorded. For each of the five-year age groups and each gender we calculated the numbers with fractures, dislocations, soft tissue injuries, ligamentous injuries and lacerations and derived average age and gender-specific prevalence as well as seasonal variations.

Results:

A total of 18890 adults were admitted, 13870 (73.4%) males and 5020 (26.6%) females. There were 8204 (43.4%) fractures. The male fracture age distribution curve was unimodal and there was a detectable bimodal pattern in females. Under 65 years males are 3 times more likely to sustain a fracture than females which decreases to equal risk over the age of 65. The most common fracture site was distal radius/ulna (13.8%), followed by tibial diaphysis (8.8%), proximal femur (7.8%), finger phalanges (6.4%), metacarpals (6%) and metatarsals (5.9%). There were seasonal variations in fracture incidence with peaks in February, March and October. The least number of fractures occurred in June.

Conclusions:

The risk of traumatic injuries is higher among specific age groups with different patterns emerging for men and women. Thus, the descriptive epidemiology will provide useful information for treatment or injury prevention strategies, resource allocation, and training priorities.

Effects of early and late treatments of low-intensity, high-frequency mechanical vibration on bone parameters in rats

Low-intensity, high-frequency mechanical vibration (LHMV) has shown to increase bone formation. However, studies comparing the effectiveness of early- and late-treatments of LHMV to counteract bone loss have not been documented. This study was designed to compare the effects of early- and late-treatments of LHMV (at 30 Hz/0.6 g, 20 min per day/five days per week, for 12 weeks) on bone parameters in ovariectomized (Ovx) rats. Thirty days after ovariectomy, 40 adult rats were randomly divided into four groups: GI (early control group); GII treated with LHMV 3 weeks after Ovx (early treatment); GIII (late control group) and GIV treated with LHMV twelve weeks after Ovx (late treatment). Bone mineral density (BMD) was analyzed before Ovx and after treatments. Then, animals were killed, and the femurs were collected and their length and diaphysis diameter were measured; the distal femurs were taken and processed for histomorphometry and polarized light microscopy for collagen fibers analysis or subjected to immunohistochemistry of cleaved caspase-3 in osteocytes. Statistical analysis was done by ANOVA followed by the Bonferroni post hoc test (p < 0.05). BMD was similar among the groups before Ovx, but after treatments, it was significantly higher in GII and GIV compared with their control groups (p < 0.05). Femur length and cortical bone thickness were similar among the groups, but the diaphysis diameter of GII was higher compared with GI. Trabecular bone area was higher in the vibrated groups, but it was greater in GII (p < 0.05). Also, the vibrated groups showed the higher content collagen fibers and lower presence apoptotic osteocytes (positive caspase-3 immunoreactivity) when compared with the other groups (p < 0.05). These results suggest that both early- and late-treatments with LHMV counteract bone loss, being the early treatment more effective than the late treatment.

Effects of different doses of soy isoflavones on bone tissue of ovariectomized rats

AIM

Studies report that hormone replacement prevents osteoporosis, but there are doubts whether isoflavones are really efficient in this process. The aim of this study was to evaluate the effects of different doses of soy isoflavones on bone tissue of ovariectomized rats.

METHODS

Forty female rats at the age of 6 months were ovariectomized and, after 3 months, the animals were divided into four groups: GI - Control (treated with drug vehicle); GII - treated with isoflavones (80 mg/kg per day); GIII - treated with isoflavones (200 mg/kg per day) and GIV - treated with isoflavones (350 mg/kg per day). Soy isoflavones were administered by gavage for 90 consecutive days. After treatment, the rats were euthanized and their distal femurs were removed for histological routine, histochemistry and biochemical study. Histological sections were stained with hematoxylin-eosin or subjected to picrosirius red and alcian blue methods. Shafts of femurs were submitted to biochemical assay and tibias were subjected to biophysical and biomechanical tests.

RESULTS

In distal femurs, the trabecular bone volume was higher in the groups treated with isoflavones, being higher in GIV, while the cortical bone width and the presence of mature type I collagen fibers were higher in GII. At the trabecular bone region, the percentage of total glycosaminoglycans (GAGs) was higher in GII and the percentage of only sulfated GAGs was higher in GIII, while the higher content of chondroitin sulfate in shafts of femurs was seen in GIV. Biophysical and biomechanical tests in tibias did not differ among the groups.

CONCLUSION

Our data indicate that soy isoflavones improve bone quality in femurs of rats by increasing histomorphometric parameters, the content of GAGs and mature type I collagen fibers. These positive effects are dose-dependent and it was different in cortical and trabecular bone.

Evidence-based practice: best imaging practice in musculoskeletal disorders

As musculoskeletal disorders are a common cause of emergency department visits in the United States, it is vital for nurses and nurse practitioners to understand the decision rules for ordering imaging tests when triaging patients with musculoskeletal complaints. Proper knowledge and command of selecting the most appropriate imaging for these frequent emergency department presentations will help reduce costs, decrease ionizing radiation exposure, and increase patient throughput. This article reviews the current evidence-based literature for musculoskeletal imaging in the emergency department and discusses the epidemiology, etiology, management, and prevention of the most common musculoskeletal disorders.

The burden of osteoporosis in Brazil

Osteoporotic fractures impose severe physical, psychosocial, and financial burden both to the patient and the society. Studies on the prevalence of osteoporosis and fragility fractures in Brazil show a wide variation, due to differences in sample size, the population studied, and methodologies. Few studies have been conducted in Brazil about the cost-effectiveness analyses of different intervention options aimed at the diagnosis and treatment of osteoporosis. Investigation and treatment strategies based on cost-effectiveness and scientific evidence are essential in the preparation of public health policies with the ultimate goal of reducing the incidence of fractures and, consequently, the direct and indirect costs associated with them. This article reviews the Brazilian burden of osteoporosis in terms of the prevalence and fractures attributable to the disease, the costs related to the investigation and management, as well as the impact of osteoporosis on the population as a whole and on affected individuals.

Development and validation of a tool for identifying women with low bone mineral density and low-impact fractures: the São Paulo Osteoporosis Risk Index (SAPORI)

The performance of the São Paulo Osteoporosis Risk Index (SAPORI) was tested in 1,915 women from the original cohort, São Paulo Osteoporosis Study (SAPOS) (N = 4332). This new tool was able to identify women with low bone density (spine and hip) and low-impact fracture, with an area under the receiving operator curve (ROC) of 0.831, 0.724, and 0.689, respectively.

INTRODUCTION

A number of studies have demonstrated the clinical relevance of risk factors for identifying individuals at risk of fracture (Fx) and osteoporosis (OP). The SAPOS is an epidemiological study for the assessment of risk factors for Fx and low bone density in women from the community of the metropolitan area of São Paulo, Brazil. The aim of the present study was to develop and validate a tool for identifying women at higher risk for OP and low-impact Fx.

METHODS

A total of 4,332 pre-, peri-, and postmenopausal women were analyzed through a questionnaire addressing risk factors for OP and Fx. All of them performed bone densitometry at the lumbar spine and proximal femur (DPX NT, GE-Lunar). Following the identification of the main risk factors for OP and Fx through multivariate and logistic regression, respectively, the SAPORI was designed and subsequently validated on a second cohort of 1,915 women from the metropolitan community of São Paulo. The performance of this tool was assessed through ROC analysis.

RESULTS

The main and significant risk factors associated with low bone density and low-impact Fx were low body weight, advanced age, Caucasian ethnicity, family history of hip Fx, current smoking, and chronic use of glucocorticosteroids. Hormonal replacement therapy and regular physical activity in the previous year played a protective role (p < 0.05). After the statistical adjustments, the SAPORI was able to identify women with low bone density (T-score ≤ -2 standard deviations) in the femur, with 91.4% sensitivity, 52% specificity, and an area under the ROC of 0.831 (p < 0.001). At the lumbar spine, the performance was similar (81.5% sensitivity, 50% specificity, and area under ROC of 0.724; p < 0.001). Regarding the identification of low-impact Fx, the sensitivity was 71%, the specificity was 52%, and the area under the ROC was 0.689 (p < 0.001).

CONCLUSION

The SAPORI is a simple, useful, fast, practice, and valid tool for identifying women at higher risk for low bone density and osteoporotic fractures.