[Incidence and socioeconomic burden of hip fractures in Italy: extension study 2003-2005]

Prognostic Value of Glycated Hemoglobin in Frail Older Diabetic Patients With Hip Fracture

BACKGROUND

Previous studies have shown increased risk of fracture in older patients with poor or strict glycemic control (glycated hemoglobin, HbA1c, ≥ 8% or < 6-7% respectively); however, these reports did not investigate the oldest-old population. Comprehensive geriatric assessment (CGA) and a patient-centered approach have been proven to improve the quality of care in the management of Type 2 Diabetes Mellitus (T2DM) in the older patients, but data regarding T2DM in patients with fragility fractures are still lacking.

AIM

To investigate the prognostic role of HbA1c and frailty level in older diabetic patients admitted for hip fracture.

METHODS

Prospective observational cohort study conducted on diabetic geriatric patients consecutively hospitalized for hip fracture in the orthogeriatric unit of a tertiary care hospital. Preoperative comprehensive geriatric assessment (CGA) was performed. Using the Clinical Frailty Scale (CFS), diabetic patients were categorized in robust (CFS < 5) and frail (CFS ≥ 5), and further stratified according to HbA1c values [Tertile 1 (T1) HbA1c < 48 mmol/mol, Tertile 2 (T2) 48-58 mmol/mol and Tertile 3 (T3) > 58 mmol/mol). Comparisons between continuous variables were performed with analysis of non-parametric test for independent samples, while relationships between categorical variables were assessed by chi-square test. Using logistic multivariate regression, we evaluated the determinants of 1-year all-cause mortality in diabetic older patients with hip fracture.

RESULTS

Among the 1319 older patients (mean age 82.8 ± 7.5 years, 75.9% females) hospitalized for hip fracture, 204 (15.5%) had a previous diagnosis of T2DM. T2DM patients showed an increased proportion of multiple concurrent fractures occurred during the accidental fall or syncope (12.7% vs 11.2%, p=0.02). One-year mortality after hip fracture surgery was significantly higher in T2DM as compared to not diabetic patients (21.2% vs 12.5%, p<0.001). No significant difference in mortality was found across HbA1c tertiles; however, frail diabetic patients in the second and third HbA1c tertiles showed higher mortality risk compared to the robust counterparts (26.9% vs 5%, p=0.001 for T2 and 43.5% vs 13.3%, p=<0.05 for T3), while no difference was observed among those in T1.

CONCLUSIONS

Frail patients with HbA1c ≥ 48 mmol/L showed an increased mortality risk as compared to robust counterparts. CFS represents an important tool to select diabetic subjects with higher likelihood of adverse outcome.

Guidelines for the management of osteoporosis and fragility fractures

The purpose of this document, a result of the harmonisation and revision of Guidelines published separately by the SIMFER, SIOMMMS/SIR, and SIOT associations, is to provide practical indications based on specific levels of evidence and various grades of recommendations, drawn from available literature, for the management of osteoporosis and for the diagnosis, prevention, and treatment of fragility fractures. These indications were discussed and formally approved by the delegates of the Italian Scientific Associations involved in the project (SIE, SIGG, SIMFER, SIMG, SIMI, SIOMMMS, SIR, and SIOT).

Impairment of PTX3 expression in osteoblasts: a key element for osteoporosis

Pentraxin 3 (PTX3) is a multifunctional glycoprotein regulating inflammatory response, cell proliferation and migration and deposition and remodelling of the extracellular matrix by a variety of cells. In this study, we investigated the possible role of PTX3 in bone homeostasis. To this end, we compared the expression and function of PTX3 in human osteoblasts of osteoporotic, osteoarthritic patients and young subjects not affected by bone diseases. Immunohistochemical analysis performed on bone head biopsies showed a close association between bone health and the number of osteoblasts expressing PTX3. Noteworthy, the proportion of PTX3-positive osteoblasts resulted to be significantly lower in osteoporotic patients compared with both young patients and osteoarthritic patients of the same age. Ex vivo culture of osteoblasts isolated from the three groups of patients confirmed in vivo observation. Specifically, we observed rare runt-related transcription factor 2 (RUNX2) immunopositive osteoblasts expressing PTX3 in cell cultures derived from osteoporotic patients and western blotting analysis showed 80% reduction of PTX3 in the corresponding culture extracts compared with young and osteoarthritic patients. The treatment of human osteoblast primary cultures derived from young patients with anti-PTX3 antibody dramatically affected osteoblast behaviour. Indeed, they lost the morphological and molecular features typical of mature osteoblasts, acquiring fibroblast-like shape and highly decreasing nuclear factor kappa-B ligand (RANKL) and RUNX2 expression. Also, the inhibition of PTX3 negatively affected osteoblast proliferation and their ability to form cell clusters and microhydroxyapatite crystals. Altogether, these results suggest a central role of PTX3 in bone homeostasis showing its involvement in osteoblast proliferation, differentiation and function.

Bone Morphogenetic Proteins and myostatin pathways: key mediator of human sarcopenia

BACKGROUND

Sarcopenia, osteoporosis and osteoarthritis are the most frequent musculoskeletal disorders affecting older people. The main aim of this study was to test the hypothesis that the balance between BMPs and myostatin pathways regulates the age-related muscle degeneration in OP and OA patients. To this end, we investigated the relationship among the expression of BMP-2/4-7, myostatin and phosphorylated Smads1-5-8 and the muscle quality, evaluated in term of fibers atrophy and satellite cells activity.

METHODS

In this retrospective study, we collected 123 biopsies of vastus lateralis: 48 biopsies from patients who underwent hip arthroplasty for subcapital fractures of the femur (OP), 55 biopsies from patients who underwent hip arthroplasty for osteoarthritis (OA) and 20 biopsies from patients who underwent hip arthroplasty for high-energy hip fractures (CTRL). Muscle biopsies were fixed in 4% paraformaldehyde and paraffin embedded. Serial sections were used for morphometrical and immunohistochemical analysis (BMP/2/4-7, myostatin, Smads1-5-8, Pax7 and myogenin). In addition, 1 mm³ of muscle tissue of each patient was embedded in epon for ultrastructural study.

RESULTS

Morphometric data indicated an increase of the number of atrophic fibers in OP patients compare to OA. In line with these data, we found an high regenerative potential in muscle tissues of OA patients due to the significant amount of both Pax7 and myogenin positive satellite cells detected in OA group. In addition, our data showed the decrease of BMP2/4 and -7 expression in OP patients compared to both OA group and CTRL. Conversely, OP patients were characterized by high levels of myostatin expression. A different expression profile was also found for phosphorylated Smad1-5-8 between OP and OA patients. In particular, OP patients showed a low number of positive phosphorylated Smad1-5-8 nuclei.

CONCLUSION

The identification of molecular pathways involved in the pathogenesis of sarcopenia open new prospective for the development of drugs able to prevent/treat the muscle impairment that occur in elderly. Results here reported, highlighting the role of BMPs and myostatin pathways in physio-pathogenesis of human sarcopenia, allow us to propose human recombinant BMP-2/7 and anti-myostatin antibodies as a possible therapeutic option for the sarcopenia.

Surgical prevention of femoral neck fractures in elderly osteoporotic patients. A literature review

Fragility fractures of the femur are one of the major causes of morbidity and mortality worldwide. The incidence of new contralateral hip fractures in elderly osteoporotic patients ranges from 7 to 12% within 2 years after the first fracture. Secondary prevention can be divided in: pharmacological therapy based on the prescription of anti-osteoporotic drugs with different mechanism of action and non-pharmacological therapy which is based on modification of environmental risk factors, on a healthy diet with daily supplements of calcium and vitamin D and calcium and on the use of hip protectors. Recently a new form of prevention is becoming achievable: surgical prevention; the rationale of surgical reinforcement is the need to increase the resistance of the femoral neck to the compression and distraction forces acting on it. In this paper we analyse all the experimental and "on the market" device available for the surgical prevention of femoral neck fracture.

Bone care nurses and the evolution of the nurse's educational function: the Guardian Angel(®) research project

Osteoporosis mostly affects females over 50 years old, worldwide. The main osteoporosis complication is fragility fractures that reduce quality of life and cause morbidity and mortality. Most patients who have fragility fractures are treated for the fracture. However, patients' adherence to follow-up treatment plans is poor. Therefore, tailored educational interventions are needed to improve medication adherence and healthy lifestyles. In this context, the role of bone care nurses is important, as they can act at different levels of osteoporosis prevention and fracture liaison services, which are secondary fracture prevention programmes implemented by health care systems to treat osteoporotic patients. In Italy, a research project called Guardian Angel(®) was developed to provide tailored education to osteoporotic women in order to improve their disease management and reduce related complications.

The contribution of cortical and trabecular tissues to bone strength: insights from denosumab studies

All materials undergo an aging process which is characterized essentially by changes of the rigidity (stiffness), of the ability to absorb the stresses (toughness) and then ultimately in the mechanical resistance (strength). Both cortical and trabecular bone undergo a continuous process of structural remodeling with the main aim to preserve their biomechanical properties. An imbalance in this process, which promotes bone resorption, results in a quantitative loss of bone tissue and in a qualitative alteration of the skeletal microarchitecture, as you can see in osteoporosis, rheumatoid arthritis or bone metastases. Cortical component has a prominent role on strength therefore loss of cortical bone that is prevalent in elderly may explain the higher frequency of fractures of bones composed mainly of cortical bone such as the proximal femur. Remodeling inhibition with denosumab improved structural strength without altering material properties, that can be primarily explained by the combined effects of increased trabecular and cortical bone mass, and reductions in trabecular eroded surfaces and particularly cortical porosity. Denosumab for its mechanism of action and pharmacokinetics results in a significant, early and continued increase in BMD with enhanced bone strength improving both cortical and trabecular bone.

Pre-injury demographic patterns of patients sustaining hip fractures in malaysia

ABSTRACT

INTRODUCTION

Hip fractures entail a growing economic burden on the health care system. Study is warranted to further our understanding of its patterns and to create increased awareness in health care providers and the public.

MATERIALS AND METHODS

Data was extracted from the ongoing National Orthopaedic Registry of Malaysia (NORM), for the period June 2008 till December 2009. Patients aged 50 years and above without previous pathological fracture hip fractures were included in the study.

RESULTS

Most hip fracture patients were 70 years and above (69.5%) with a mean (SD) age of 73.8 (10.3) years. Females represented the majority of the patients in this study (68.4%). Low energy trauma (i.e. trivial fall) was to the main mechanism of hip fractures in this study (81.3%).

CONCLUSIONS

Aging adults should be made aware of timely preventive strategies (including osteoporosis prevention) fall prevention measures, and encouraged to maintain physically active lifestyles.

KEY WORDS

Hip fracture, pre-fracture status.