American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the diagnosis and treatment of postmenopausal osteoporosis

High-molecular-weight Hyaluronan Administration Inhibits Bone Resorption and Promotes Bone Formation in Young-age Osteoporosis Rats

Osteoporosis poses a significant global health concern, affecting both the elderly and young individuals, including athletes. Despite the development of numerous antiosteoporotic drugs, addressing the unique needs of young osteoporosis patients remains challenging. This study focuses on young rats subjected to ovariectomy (OVX) to explore the impact of high-molecular-weight hyaluronan (HA) on preventing OVX-induced osteoporosis. Twenty-four rats underwent OVX, while 12 underwent sham procedures (sham control group). Among the OVX rats, half received subcutaneous injections of HA (MW: 2700 kDa) at 10 mg/kg/week into their backs (OVX-HA group), whereas the other half received saline injections (0.5 ml/week) at the same site (OVX-saline group). OVX-HA group exhibited significantly higher percentages of osteoclast surface (Oc. S/BS), osteoblast surface per bone surface (Ob. S/BS), and bone volume/tissue volume (BV/TV) compared with OVX-saline group at the same age. The proportions of Ob. S/BS and BV/TV in the OVX-HA group closely resembled those of the sham control group, whereas the proportion of Oc. S/BS in the OVX-HA group was notably higher than that in the sham control group. In summary, the administration of HA significantly mitigated bone resorption and enhanced bone formation, suggesting a crucial role for HA in the treatment of young adult osteoporosis.

Protective role of exercise on breast cancer-related osteoporosis in women undergoing aromatase inhibitors: A narrative review

Hormone therapy following surgery reduces the risk of breast cancer (BC) recurrence and progression of hormone-sensitive BC, especially in postmenopausal women. Despite the antitumor efficacy of hormone therapy, particularly of aromatase inhibitors, they cause long-term side effects, mainly bone density reduction. Exercise can slow the rate of bone loss, which reduces the risk of fractures from osteoporosis, and could be an integrative treatment able to mitigate the BC treatment side effects positively impacting bone health. This narrative review aims to discuss studies on the effect of exercise on bone health in BC women undergoing aromatase inhibitors, highlighting the possible role of exercise as complementary to conventional therapies. Additionally, according to the literature revision, exercise practical applications to improve bone health in these patients are summarized.

Gut microbiota alterations in postmenopausal women with osteoporosis and osteopenia from Shanghai, China

Background

The importance of the gut microbiota in maintaining bone homeostasis has been increasingly emphasized by recent research. This study aimed to identify whether and how the gut microbiome of postmenopausal women with osteoporosis and osteopenia may differ from that of healthy individuals.

Methods

Fecal samples were collected from 27 individuals with osteoporosis (OP), 44 individuals with osteopenia (ON), and 23 normal controls (NC). The composition of the gut microbial community was analyzed by 16S rRNA gene sequencing.

Results

No significant difference was found in the microbial composition between the three groups according to alpha and beta diversity. At the phylum level, Proteobacteria and Fusobacteriota were significantly higher and Synergistota was significantly lower in the ON group than in the NC group. At the genus level, Roseburia, Clostridia_UCG.014, Agathobacter, Dialister and Lactobacillus differed between the OP and NC groups as well as between the ON and NC groups (p < 0.05). Linear discriminant effect size (LEfSe) analysis results showed that one phylum community and eighteen genus communities were enriched in the NC, ON and OP groups, respectively. Spearman correlation analysis showed that the abundance of the Dialister genus was positively correlated with BMD and T score at the lumbar spine (p < 0.05). Functional predictions revealed that pathways relevant to amino acid biosynthesis, vitamin biosynthesis, and nucleotide metabolism were enriched in the NC group. On the other hand, pathways relevant to metabolites degradation and carbohydrate metabolism were mainly enriched in the ON and OP groups respectively.

Conclusions

Our findings provide new epidemiologic evidence regarding the relationship between the gut microbiota and postmenopausal bone loss, laying a foundation for further exploration of therapeutic targets for the prevention and treatment of postmenopausal osteoporosis (PMO).

Publication Trends in Osteoporosis Treatment: A 20-Year Bibliometric Analysis

BACKGROUND

Osteoporosis prevalence continues to escalate with the growth of the older adult population. In this study, we aimed to investigate the profile of osteoporosis treatment-related research articles published in the past 20 years using bibliometric analysis.

METHODS

We analyzed all osteoporosis treatment-related articles published between 2001 and 2020 in the Web of Science (WoS) database using bibliometric methods. In the Title search section in WoS, we searched the documents using "osteoporosis treatment"-related keywords. We used the VOSviewer software to construct the bibliometric maps of keyword co-occurrences.

RESULTS

Our search yielded 29,738 publications, 21,556 (72.5%) were original articles and 4,529 (15.2%) were review articles and review articles (4,529). We noticed a steady increase in the publication numbers from 2001 to 2020. The overall scientific publication number in WoS increased 3.5-fold, with the five most productive countries being the USA, China, Germany, the United Kingdom, and Japan. The largest contributor was the University of California system. The most productive journals were Osteoporosis International (1,679, 6.4%), Bone (832, 3.2%), and the Journal of Bone and Mineral Research (727, 2.8%). We observed increasing trends in the appearance of denosumab and teriparatide during the last two decades. In our keyword co-occurrence analysis, we constructed four keyword clusters using VOSviewer.

CONCLUSIONS

In this study, we provided a gross overview of the visibility and productivity of research studies in osteoporosis treatment. Substantial changes have occurred in osteoporosis treatment over the last 20 years. The effector mechanism of anti-osteoporosis medications could be future hot spots in osteoporosis research. We believe that our study is a valuable guide for clinicians related to the global outputs of osteoporosis treatment.

Cinobufotalin prevents bone loss induced by ovariectomy in mice through the BMPs/SMAD and Wnt/β-catenin signaling pathways

BACKGROUND

Osteoporosis is a chronic bone disease characterized by bone loss and decreased bone strength. However, current anti-resorptive drugs carry a risk of various complications. The deep learning-based efficacy prediction system (DLEPS) is a forecasting tool that can effectively compete in drug screening and prediction based on gene expression changes. This study aimed to explore the protective effect and potential mechanisms of cinobufotalin (CB), a traditional Chinese medicine (TCM), on bone loss.

METHODS

DLEPS was employed for screening anti-osteoporotic agents according to gene profile changes in primary osteoporosis. Micro-CT, histological and morphological analysis were applied for the bone protective detection of CB, and the osteogenic differentiation/function in human bone marrow mesenchymal stem cells (hBMMSCs) were also investigated. The underlying mechanism was verified using qRT-PCR, Western blot (WB), immunofluorescence (IF), etc. RESULTS: A safe concentration (0.25 mg/kg in vivo, 0.05 μM in vitro) of CB could effectively preserve bone mass in estrogen deficiency-induced bone loss and promote osteogenic differentiation/function of hBMMSCs. Both BMPs/SMAD and Wnt/β-catenin signaling pathways participated in CB-induced osteogenic differentiation, further regulating the expression of osteogenesis-associated factors, and ultimately promoting osteogenesis.

CONCLUSION

Our study demonstrated that CB could significantly reverse estrogen deficiency-induced bone loss, further promoting osteogenic differentiation/function of hBMMSCs, with BMPs/SMAD and Wnt/β-catenin signaling pathways involved.

Telomere length as a predictive biomarker in osteoporosis (Review)

Telomeres are the ends of chromosomes that protect them from DNA damage. There is evidence to suggest that telomere shortening appears with advanced age. Since aging is a significant risk factor for developing age-related complications, it is plausible that telomere shortening may be involved in the development of osteoporosis. The present review summarizes the potential of telomere shortening as a biomarker for detecting the onset of osteoporosis. For the purposes of the present review, the following scientific databases were searched for relevant articles: PubMed/NCBI, Cochrane Library of Systematic Reviews, Scopus, Embase and Google Scholar. The present review includes randomized and non-randomized controlled studies and case series involving humans, irrespective of the time of their publication. In six out of the 11 included studies providing data on humans, there was at least a weak association between telomere length and osteoporosis, with the remaining studies exhibiting no such association. As a result, telomere shortening may be used as a biomarker or as part of a panel of biomarkers for tracking the onset and progression of osteoporosis.

The Use of Bone Density Scan in Monitoring Treatment Response in Patients Diagnosed with Osteoporosis: A Retrospective Cohort Study

Osteoporosis is characterized as a metabolic bone disease defined by low bone mineral density (BMD) and bone tissue degeneration, particularly a reduction in the number of trabeculae and a drop in cortical bone thickness, and a rise in porosity, which is mainly due to an imbalance between bone resorption and formation. As a result, it increases bone fragility, and the susceptibility to fracture increases, especially among the elderly. The objective is to assess the effectiveness of dual-energy X-ray absorptiometry (DXA) scan in monitoring the response to osteoporosis treatment and compare the scan's response to different osteoporosis treatments. This retrospective cohort study included 51 adults selected from 300 patients diagnosed with osteoporosis based on World Health Organization (WHO) diagnostic criteria of a T-score of -2.5. Data were acquired from the electronic medical records between 2016 and 2019 from a private hospital in Dubai, United Arab Emirates (UAE). The study included sociodemographic characteristics, biomedical parameters, comorbidities, history of fracture, medications, laboratory, and DXA scan results. Ninety-four percent of the patients were females; the mean (±SD) age was 58.1 ± 11.5 years. Most patients were expatriates (84.3%), of which Asian ethnicity was 66.7%. The mean (±SD) duration of osteoporosis was 2.82 ± 1.8 years. Eleven (21.6%) patients had a history of fragility fracture. Ninety-six percent of the patients had vitamin D deficiency. One-third (29.4%) of the patients had hyperparathyroidism. Alendronate/cholecalciferol, received by nine patients (17.6%), showed a significant improvement (p = 0.018) in the BMD of the femoral neck among the study group. In conclusion, the DXA scan as a monitoring tool has shown a significant improvement in the BMD of the femoral neck among patients taking alendronate/cholecalciferol treatment compared to other medications.

Zoledronic acid for osteoporosis after distal radius fracture surgery: Prospective longitudinal study

Background

Distal radius fractures (DRFs) are the most frequent first-ever osteoporotic fragility fractures. However, most patients are treated only for fractures and not for osteoporosis. Therefore, we investigated early osteoporosis intervention using zoledronic acid.

Methods

This prospective study enrolled 30 patients aged 50 years or older who had no history of fragility fractures or osteoporosis treatment and who underwent surgical treatment for DRFs. Patients whose lumbar spine or femur bone mineral density (BMD) values were less than 80% of the young adult mean (YAM) were treated with a 5-mg intravenous infusion of zoledronic acid. Lumbar spine and femur YAM BMD values, TRACP-5b and PINP were statistically evaluated using the paired t-test. The relationship between adverse effects, age, body mass index (BMI), and creatinine clearance (CCr) was statistically examined using Mann-Whitney's U test. The incidence of the bone fusion and secondary fractures within the 60-months postoperative period were assessed.

Results

The mean lumbar spine and femur YAM BMD values before treatment were 76.1 ± 13.1% and 70.7 ± 8.5%. This indicates osteopenia in both locations. These values differed significantly between the pre-treatment period and each subsequent period. Five patients with a target YAM BMD value over 80% within 60 months after treatment were observed. The TRACP-5b and PINP values differed significantly between the pre-treatment period and each subsequent period. Adverse drug reactions were observed in 12 patients (40%). Age, BMI, and CCr did not show statistically significant differences in the occurrence of adverse effects. Bone fusion was confirmed at a mean of 3.6 months postoperatively. Secondary fractures were observed in 3 patients within 60 months after treatment.

Conclusion

DRFs occur at a younger age than other fragility fractures, and it is important to intervene aggressively with osteoporosis treatment to prevent secondary fractures.

Level of evidence

Level V.

Fracture risk among patients with cancer compared to individuals without cancer: a population-based study

BACKGROUND

Patients with cancer may be at increased risk of osteoporosis and fracture; however, gaps exist in the existing literature and the association between cancer and fracture requires further examination.

METHODS

We conducted a population-based cohort study of Ontario patients with cancer (breast, prostate, lung, gastrointestinal, haematologic) diagnosed between January 2007 to December 2018 and 1:1 matched non-cancer controls. The primary outcome was incident fracture (end of follow-up December 2019). Multivariable Cox regression analysis was used to estimate the relative fracture risk with sensitivity analysis accounting for competing risk of death.

RESULTS

Among 172,963 cancer patients with non-cancer controls, 70.6% of patients with cancer were <65 years old, 58% were female, and 9375 and 8141 fracture events were observed in the cancer and non-cancer group, respectively (median follow-up 6.5 years). Compared to non-cancer controls, patients with cancer had higher risk of fracture (adjusted HR [aHR] 1.10, 95% CI 1.07-1.14, p < 0.0001), which was also observed for both solid (aHR 1.09, 95% CI 1.05-1.13, p < 0.0001) and haematologic cancers (aHR 1.20, 95% CI 1.10-1.31, p < 0.0001). Sensitivity analysis accounting for competing risk of death did not change these findings.

CONCLUSIONS

Our study indicates that patients with cancer are at modest risk of fractures compared to non-cancer controls.

Osteoporosis and vitamin D consumption: knowledge and practice in different Arab countries

Despite the high prevalence of osteoporosis and vitamin D deficiency, the knowledge about osteoporosis and vitamin D-related practices were moderate in some countries in the Middle East and North Africa (MENA) region. Improving knowledge through awareness campaign and screening programs is essential to enhance vitamin D-related practices.

PURPOSE

Osteoporosis is the most common skeletal disease, which usually remains silent until fractures occur. Vitamin D deficiency impairs bone mineralization and increases the risk of osteoporosis. Despite being relatively sunny, the Middle East and North Africa (MENA) region has a high prevalence of osteoporosis and hypovitaminosis D. This study aims to assess the knowledge about osteoporosis and vitamin D-related practices and to determine the correlation between them in some countries of the MENA region.

METHODS

A cross-sectional study was performed in Lebanon, Syria, Egypt, Palestine, Iraq, Jordan, and Saudi Arabia. From each country, 600 participants were enrolled. The survey included four sections: sociodemographic information, past medical history, Osteoporosis Knowledge Assessment Tool to assess the knowledge about osteoporosis, and Practice Towards Vitamin D scale to assess vitamin D-related practices.

RESULTS

Our study found that 67.14% of respondents had moderate knowledge about osteoporosis and 42.31% had moderate vitamin D-related practices. Higher knowledge level was reported in the young, females, Syrians, singles, postgraduates, and healthcare employees (p < 0.05). Better vitamin D-related practices were detected in the elderly, males, Egyptians, married, and high school or below educational level (p < 0.05). The Internet was the most listed source of information. Adequate osteoporosis knowledge was associated with better vitamin D-related practices (p < 0.001).

CONCLUSION

Most participants, representing some countries of the MENA region, displayed moderate knowledge regarding osteoporosis and moderate vitamin D-related practices. Adequate knowledge about osteoporosis is essential to improve practices, so awareness campaigns and screening programs should be more frequently implemented.

Eleven years secular trend of the initiation of anti-osteoporosis medications and subsequent fractures in Taiwan: From 2008 to 2018

BACKGROUND

Osteoporosis is a common metabolic bone disease that benefits from many newly developed anti-osteoporosis medications (AOMs). Reimbursement policies need to allocate medical budgets properly based on evidence-based data. This study aimed to investigate the 11-year secular trend, focusing on older age and males in this adjustment wave of the National Health Insurance reimbursement.

METHODS

We adopted a nationwide cohort from Taiwan's National Health Insurance Research Database (NHIRD). Patients undergoing newly initiated AOMs from 2008 to 2018 were included. The AOMs in this study included denosumab, zoledronate, ibandronate, alendronate, raloxifene, and risedronate. Patients <50 years, pathological fractures, missing data, and two AOMs prescribed were excluded. The real-world trends related to subsequent fragility fracture and death within 1 and 3 years were used to evaluate the potential effects due to revision of reimbursement policies.

RESULTS

Of 393,092 patients, among them, 336,229 patients met the criteria, whose mean age ranged from 73.3 to 74.4 years, and nearly 80% were female. Further analysis showed a steady increase of AOMs from 5567 (17.1%) and 8802 (27.0%) in 2008-6697 (18.3%) and 10,793 (29.5%) in 2018 for males and 80+ years respectively. The subsequent fragility fracture within one and three years post AOMs initiation was 5.81% and 11.80% in 2018.

CONCLUSION

This study showed an immediate drop in AOMs prescription after the implementation of a new stricter reimbursement policy. It took 5 years to return the annual prescription number.

An analysis of cost and complications for patients sustaining a second, contralateral hip fracture within 1 year

INTRODUCTION

Hip fractures are an increasingly common occurrence among the aging population. With increased life expectancy and advancements in medicine, patients sustaining a hip fracture are at an increasing risk of sustaining a contralateral hip fracture. Efforts are being made to better understand the environment of these hip fractures so that secondary prevention clinics and guidelines can be made to help prevent recurrent osteoporotic hip fractures. The estimated incidence of a contralateral hip fracture varies from 2 to 10% and is reportedly associated with a higher incidence of complications. Previous studies evaluating contralateral hip fractures compared a single cohort of patients sustaining a second hip fracture with patients who sustained only one hip fracture. We aimed to investigate the overall complications and associated costs as it relates to a patients first hip fracture and contrast this to the same patient's contralateral, second hip fractures.

METHODS

We performed a retrospective review of all patients in our health systems electronic database who were found to have surgically treated hip fractures between January 2004 and July 2019. Patients with surgically treated hip fractures (CPT Codes: 27235, 27236, 27245, 27244), who sustained a second contralateral hip fracture were included. Medical complications within 30 days of either procedure (such as pneumonia, UTI, altered mental status and others), length of stay, orthopedic complications (such as wound complications, infection, hardware failure, nonunion), type of implants, costs, comorbidities, and ASA Class as well as Mortality were reviewed.

RESULTS

A total of 4,870 hip fractures were identified during the study period where 137 (2.8%) patients sustained a second hip fracture, and 47 (0.9%) of which were sustained within the first year after their index hip fracture. There was no statistical difference in length of stay (p = 0.68), medical (p>0.99) or orthopedic complications (p>0.99) between patients first and second hip fractures. There was an increased incidence of cognitive impairment with the second hip fracture (P = 0.0002). For patients that underwent operative treatment of a second hip fracture, the total cost of care was higher for the second surgery (mean difference 757. 38 USD) however the difference wasn't statistically significant (p = 0.31). The overall 1-year mortality rate was 14.9 percent.

CONCLUSIONS

Our study demonstrates there is no statistical difference between the first and second surgery regarding length of stay, medical or orthopedic complications and cost.

Dual-Energy X-Ray Absorptiometry Scan Utilization and Skeletal Fragility Among Non-Infectious Uveitis Patients Exposed to Oral Glucocorticoids

INTRODUCTION

Currently, little is known regarding bone health surveillance for glucocorticoid-exposed non-infectious uveitis (NIU) patients or their baseline risks of skeletal fragility outcomes.

METHODS

Using claims data, we calculated rates of dual-energy x-ray absorptiometry (DXA) screening for glucocorticoid-exposed NIU and rheumatoid arthritis (RA) patients. Separately, we compared risks of skeletal fragility metrics amongst NIU patients, RA patients, and controls, independent of glucocorticoid use.

RESULTS

The adjusted hazard ratio (aHR) of NIU patients to have a DXA scan was 0.64 (95% CI, 0.63-0.65; p < .001) compared to RA patients. The aHR for any skeletal fragility outcome amongst NIU patients was 0.97 (p < .02) compared to normal controls, while RA patients had excess risk (aHR, 1.15; p < .001).

CONCLUSIONS

NIU patients are 36% less likely to receive a DXA scan after high-dose glucocorticoid exposure compared with RA patients. No elevated risk of osteoporosis for NIU patients was found compared to normal controls.

Continuum finite element analysis generalizesin vivotrabecular bone microstructural strength measures between two CT scanners with different image resolution

Fragility of trabecular bone (Tb) microstructure is increased in osteoporosis, which is associated with rapid bone loss and enhanced fracture-risk. Accurate assessment of Tb strength usingin vivoimaging available in clinical settings will be significant for management of osteoporosis and understanding its pathogenesis. Emerging CT technology, featured with high image resolution, fast scan-speed, and wide clinical access, is a promising alternative forin vivoTb imaging. However, variation in image resolution among different CT scanners pose a major hurdle in CT-based bone studies. This paper presents nonlinear continuum finite element (FE) methods for computation of Tb strength fromin vivoCT imaging and evaluates their generalizability between two scanners with different image resolution. Continuum FE-based measures of Tb strength under different loading conditions were found to be highly reproducible (ICC ≥ 0.93) using ankle images of twenty healthy volunteers acquired on low- and high-resolution CT scanners 44.6 ± 2.7 days apart. FE stress propagation was mostly confined to Tb micro-network (2.3 ± 1.7 MPa) with nominal leakages over the marrow space (0.4 ± 0.5 MPa) complying with the fundamental principle of mechanics atin vivoimaging. In summary, nonlinear continuum FE-based Tb strength measures are reproducible among different CT scanners and suitable for multi-site longitudinal human studies.

m2ABQ-a proposed refinement of the modified algorithm-based qualitative classification of osteoporotic vertebral fractures

Currently, there is no reproducible, widely accepted gold standard to classify osteoporotic vertebral body fractures (OVFs). The purpose of this study is to refine a method with clear rules to classify OVFs for machine learning purposes. The method was found to have moderate interobserver agreement that improved with training.

INTRODUCTION

The current methods to classify osteoporotic vertebral body fractures are considered ambiguous; there is no reproducible, accepted gold standard. The purpose of this study is to refine classification methodology by introducing clear, unambiguous rules and a refined flowchart to allow consistent classification of osteoporotic vertebral body fractures.

METHODS

We developed a set of rules and refinements that we called m2ABQ to classify vertebrae into five categories. A fracture-enriched database of thoracic and lumbar spine radiographs of patients 65 years of age and older was retrospectively obtained from clinical institutional radiology records using natural language processing. Five raters independently classified each vertebral body using the m2ABQ system. After each annotation round, consensus sessions that included all raters were held to discuss and finalize a consensus annotation for each vertebral body where individual raters' evaluations differed. This process led to further refinement and development of the rules.

RESULTS

Each annotation round showed increase in Fleiss kappa both for presence vs absence of fracture 0.62 (0.56-0.68) to 0.70 (0.65-0.75), as well as for the whole m2ABQ scale 0.29 (0.25-0.33) to 0.54 (0.51-0.58).

CONCLUSION

The m2ABQ system demonstrates moderate interobserver agreement and practical feasibility for classifying osteoporotic vertebral body fractures. Future studies to compare the method to existing studies are warranted, as well as further development of its use in machine learning purposes.

Adrenal venous sampling in primary aldosteronism: Experience of a Spanish multicentric study (Results from the SPAIN-ALDO Register)

OBJECTIVE

The aim of this study was to evaluate the rate of adrenal venous sampling (AVS) performance in patients with primary aldosteronism (PA), the main reasons for its non-performance, and the success and complications rate of this procedure in Spain. Moreover, the concordance between CT/MRI and AVS for PA subtyping was evaluated.

METHODS

A retrospective multicenter study of PA patient follow-up in 20 Spanish tertiary hospitals between 2018-2021 was performed (SPAIN-ALDO Register).

RESULTS

Of the 440 patients with PA included in the study, 153 underwent AVS (34.8%). The main reasons for not performing AVS were: patient rejection to the procedure, low catheterization rate in the center and unilateral disease based on CT/MRI. The overall success rate was 44.4% (the left adrenal vein was properly canulated in 77.8% and the right adrenal vein in 48.4%). Only 3 patients experienced minor complications. In the 45 patients with unilateral disease according to AVS, CT/MRI indicated bilateral disease or normal adrenal glands in 17. In the 23 patients with bilateral disease, CT/MRI indicated unilateral disease in 14. However, no significant differences were observed in biochemical response (P = 0.051) and hypertension resolution (P = 0.150) between patients who underwent surgery based on CT/MRI results and those who underwent surgery based on AVS results.

CONCLUSION

In our setting, AVS is still an underused technique in patients with PA. The low experience and success rate in AVS partially justify these results. More training for providers and patients needs to be done to include appropriate well performed AVS in the diagnosis algorithm of PA.

Fecal microbiota transplantation as a promising treatment option for osteoporosis

Osteoporosis is a systemic metabolic bone disease characterized by the descending bone mass and destruction of bone microstructure, which tends to result in the increased bone fragility and associated fractures, as well as high disability rate and mortality. The relation between gut microbiota and bone metabolism has gradually become a research hotspot, and it has been verified that gut microbiota is closely associated with reduction of bone mass and incidence of osteoporosis recently. As a novel "organ transplantation" technique, fecal microbiota transplantation (FMT) mainly refers to the transplantation of gut microbiota from healthy donors to recipients with gut microbiota imbalance, so that the gut microbiota in recipients can be reshaped and play a normal function, and further prevent or treat the diseases related to gut microbiota disorder. Herein, based on the gut-bone axis and proven regulatory effects of gut microbiota on osteoporosis, this review expounds relevant basic researches and clinical practice of FMT on osteoporosis, thus demonstrating the potentials of FMT as a therapeutic option for osteoporosis and further providing certain reference for the future researches.

In Vivo Comparison of Backscatter Techniques for Ultrasonic Bone Assessment at the Femoral Neck

Ultrasonic techniques are being developed to detect changes in cancellous bone caused by osteoporosis. The goal of this study was to test the relative in vivo performance of eight backscatter parameters developed over the last several years for ultrasonic bone assessment: apparent integrated backscatter (AIB), frequency slope of apparent backscatter (FSAB), frequency intercept of apparent backscatter (FIAB), normalized mean of the backscatter difference (nMBD), normalized slope of the backscatter difference (nSBD), normalized intercept of the backscatter difference (nIBD), normalized backscatter amplitude ratio (nBAR) and backscatter amplitude decay constant (BADC). Backscatter measurements were performed on the left and right femoral necks of 80 adult volunteers (age = 25 ± 11 y) using an imaging system equipped with a convex array transducer. For comparison, additional ultrasonic measurements were performed at the left and right heel using a commercially available heel-bone ultrasonometer that measured the stiffness index. Six of the eight backscatter parameters (all but nSBD and nIBD) exhibited similar and highly significant (p < 0.000001) left-right correlations (0.51 ≤ R ≤ 0.68), indicating sensitivity to naturally occurring variations in bone tissue. Left-right correlations for the stiffness index measured at the heel (R = 0.75) were not significantly better than those produced by AIB, FSAB and FIAB. The short-term precisions of AIB, nMBD, nBAR and BADC (7.8%-11.7%) were comparable to that of the stiffness index measured with the heel-bone ultrasonometer (7.5%).

Management of Osteoporosis and Spinal Fractures: Contemporary Guidelines and Evolving Paradigms

Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying diminished bone mineral density, as worldwide fracture prevention campaigns are trailing behind in meeting their goals. This is a narrative review exploring the various imaging and laboratory tests used to diagnose osteoporotic fractures and a comprehensive compilation of contemporary medical and surgical management. We have incorporated salient recommendations from the Endocrine Society, the American Association of Clinical Endocrinology (AACE), and the American Society for Bone and Mineral Research (ASBMR). The use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis with a 10-year probability of hip fracture and major fractures in the spine, forearm, hip, or shoulder is highlighted. This osteoporosis risk assessment tool can be easily incorporated into the preoperative bone health optimization strategies, especially before elective spine surgery in osteoporotic patients. The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature. We also aim to present an evidence-based clinical management algorithm for treating osteoporotic vertebral body compression fractures, tumor-induced osteoporosis, or hardware stabilization in elderly trauma patients in the setting of their impaired bone health. The recent guidelines and recommendations on surgical intervention by various medical societies are covered, along with outcome studies that reveal the efficacy of cement augmentation of vertebral compression fractures via vertebroplasty and balloon kyphoplasty versus conservative medical management in the elderly population.

New Horizons for Hydroxyapatite Supported by DXA Assessment-A Preliminary Study

Dual Energy X-ray Absorptiometry (DXA) is a tool that allows the assessment of bone density. It was first presented by Cameron and Sorenson in 1963 and was approved by the Food and Drug Administration. Misplacing the femoral neck box, placing a trochanteric line below the midland and improper placement of boundary lines are the most common errors made during a DXA diagnostic test made by auto analysis. Hydroxyapatite is the most important inorganic component of teeth and bone tissue. It is estimated to constitute up to 70% of human bone weight and up to 50% of its volume. Calcium phosphate comes in many forms; however, studies have shown that only tricalcium phosphate and hydroxyapatite have the characteristics that allow their use as bone-substituted materials. The purpose of this study is aimed at analyzing the results of hip densitometry and hydorxyapatite distribution in order to better assess the structure and mineral density of the femoral neck. However, a detailed analysis of the individual density curves shows some qualitative differences that may be important in assessing bone strength in the area under study. To draw more specific conclusions on the therapy applied for individual patients, we need to determine the correct orientation of the bone from the resulting density and document the trends in the density distribution change. The average results presented with the DXA method are insufficient.

The Microbiota-Bone-Allergy Interplay

Emerging knowledge suggests an increasing importance of gut microbiota in health and disease. Allergy and bone metabolism are closely interconnected, and the possible negative effects of common therapies are not the only aspects of this relationship. The immune system is influenced by the microbiota-host interactions, and several pieces of evidence suggest the existence of an interplay between microbiota, bone metabolism, and allergies. Understanding these inter-relationships is essential for the development of new potential strategies of treatment and prevention targeting microbiota. A wide range of substances and germs, prebiotics and probiotics, are capable of influencing and modifying the microbiota. Prebiotics and probiotics have been shown in several studies to have different actions based on various factors such as sex, hormonal status, and age. In this review, we summarize the latest knowledge on the topic, and we discuss practical implications and the need for further studies.

Treatment of bisphosphonate induced osteonecrosis of jaw in rats using an angiogenesis factor (A-Heal) and ABMDO (Autologous Bone Marrow Derived Osteoblasts)

Background and objective

Materials and methods

Results

Conclusion

Osteoporosis therapies and their mechanisms of action (Review)

Osteoporosis is a common disease that affects millions of patients worldwide and is most common in menopausal women. The main characteristics of osteoporosis are low bone density and increased risk of fractures due to deterioration of the bone architecture. Osteoporosis is a chronic disease that is difficult to treat; thus, investigations into novel effective therapeutic methods are required. A number of studies have focused on determining the most effective treatment options for this disease. There are several treatment options for osteoporosis that differ depending on the characteristics of the disease, and these include both well-established and newly developed drugs. The present review focuses on the various drugs available for osteoporosis, the associated mechanisms of action and the methods of administration.

Correlational analysis of bone health status and vitamin D-related biomarkers in women working in agriculture

The purpose of this study was to investigate the status of bone health in women working in agriculture and analyze the associations between bone health and various vitamin D-related biomarkers.This observational study enrolled women working in agriculture (n = 210) and control occupations (n = 180). The concentration of serum total 25-hydroxy vitamin D [25(OH)D] was measured using the Elecsys Vitamin D Total Kit, and serum vitamin D-binding protein (VDBP) was measured by enzyme-linked immunosorbent assay. Along with albumin, 25(OH)D and VDBP were used to calculate the concentrations of bioavailable and free 25(OH)D. Bone mineral density (BMD) and T-score were measured at lumbar 1 to 4 and the femur neck using dual-energy X-ray absorptiometry. To identify factors affecting BMD, log-linear model and linear regression analysis were performed for statistical analysis.Agricultural women workers showed higher serum concentrations of bioavailable 25(OH)D (12.8 ± 3.7 vs 8.7 ± 5.1 ng/mL) and lower VDBP concentrations (201.8 ± 45.0 vs 216.0 ± 68.2 μg/mL) than control women. The association between these 2 vitamin D related-biomarkers and femur neck BMD were confirmed through univariable and multivariable linear model analysis. Although lumbar BMD did not differ between groups, the agricultural group displayed a lower femur BMD and a 4.3-fold increase in the risk of osteoporosis compared with the control group.Women working in agriculture showed lower femur BMD than the control group. Of the vitamin D-related biomarkers tested, bioavailable 25(OH)D and VDBP were associated with BMD. As bioavailable 25(OH)D levels are affected mainly by VDBP levels, VDBP may play a role in the lower femur neck BMD values observed in the agricultural group. Thus, the measurement of VDBP concentration might be considered a simple and non-invasive method for measuring bone health status.

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 guidelines from a rehabilitation perspective: systematic analysis and quality appraisal using AGREE II

INTRODUCTION

People affected by osteoporosis and fragility fractures often report disability and poor health-related quality of life. Albeit rehabilitation has a crucial role in older people, post-menopausal women and other subjects with high risk of fragility fractures, the rehabilitation perspective has been poorly investigated in the available guidelines for osteoporosis. The aim of this systematic review was to systematically evaluate the quality of guidelines for osteoporosis from a rehabilitation perspective.

EVIDENCE ACQUISITION

On May 2020, we performed a systematic search on medical literature of all guidelines published in the last 10 years on PubMed, Pedro, and international guideline databases. The study selection was based on key terms "exercise," "physical activity" or "rehabilitation." All authors independently assessed the methodological quality through the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, consisting of six domains (scope, stakeholder involvement, rigor and development, clarity of presentation, applicability, editorial independence).

EVIDENCE SYNTHESIS

Out of 331 documents retrieved, a total of 34 guidelines were selected after the screening phases. Twenty (58.8%) high quality guidelines were reported. According to AGREE II instrument, a mean score of 78.1±21.8% was reported for "scope and purpose" domain; for stakeholder involvement, the mean score was 58.1±22.1%; the rigor of development was good (mean score of 61.3±27.3%); for clarity of presentation the mean score was 79.4±20.3%; the applicability was poor (mean score of 30.9±25.2%); for editorial independence the mean score was 75.1±24.6%. Rehabilitation recommendations for osteoporotic patients were reported in 21 (61.8%) of the selected guidelines.

CONCLUSIONS

This is the first systematic analysis evaluating quality of the guidelines for osteoporosis using AGREE II instrument. Starting from a state of the art of the currently available evidence, we could conclude that therapeutic exercise at moderate to high intensity is encouraged by several guidelines for the management of people with osteoporosis and fragility fractures. More than half of guidelines were of high-quality. However, most guidelines are lacking specific indications about exercise features. This study might support the implementation of a rehabilitation perspective in the guidelines for osteoporotic patients.

QingYan formula extracts protect against postmenopausal osteoporosis in ovariectomized rat model via active ER-dependent MEK/ERK and PI3K/Akt signal pathways

ETHNOPHARMACOLOGICAL RELEVANCE

QingYan Formula has been traditionally used to tonify kidney and benefit essence, and QingYan Formula 70% ethanol extracts (QYFE) showed estrogen-like effect on reproductive system in our previous studies. However, there were no reports of QYFE on bone.

AIM OF THE STUDY

This study offered preliminary insight of QYFE into the pharmacodynamics and mechanism of anti-bone osteoporosis in ovariectomized rats.

MATERIALS AND METHODS

OVX rats were orally administrated QYFE or estradiol valerate (EV) for 12 weeks. We investigated the pharmacodynamic effects of QYFE on anti-bone loss in OVX rats, and also investigated the role of QYFE in promoting osteogenesis and inhibiting osteoclast differentiation.

RESULTS

QYFE administration significantly reduced the degree of high bone turnover, dose-dependently repaired the damaged microstructure of trabecular and cortical bone by Hematoxylin-Eosin (HE) staining and micro-computed tomography (micro-CT), and reduced the number of femur osteoclasts by TRAP staining. QYFE enhanced the proliferation and activity of alkaline phosphatase (ALP), the phosphorylation levels of extracellular regulated kinase (ERK) and Akt in MG-63 cells, which was inhibited by ICI 182 780. Moreover, in RAW264.7 cells, QYFE inhibited osteoclasts differentiation, reduced the number of osteoclasts, decreased the activity of TRAP enzyme during formation, down-regulated the protein expression of p-ERK inhibited by ICI 182 780 and p-Akt not inhibited by ICI 182 780.

CONCLUSION

This experiment demonstrated that QYFE had a definite anti-bone loss effect and had potential effect on postmenopausal osteoporosis. The molecular mechanism was related to the activation of estrogen receptor (ER)-dependent mitogen-activated protein kinase kinase (MEK)/ERK and phosphoinositide 3-kinase (PI3K)/Akt signal pathways in osteoblast, down-regulation protein expressions of ER-dependent p-ERK and ER-independent p-Akt in osteoclast.

A Single-Center Prospective Study of 116 Women with Osteoporosis Treated with Zoledronic Acid Monitored by Electrocardiography for the Development of Cardiac Arrhythmia During the Acute Phase in China

Background

Concerns have been raised among clinicians and patients about the cardiovascular risks of bisphosphonates used in the treatment of osteoporosis. The goal of this study was to investigate the acute effect of zoledronic acid (ZA) infusion on arrhythmia development using an electrocardiograph (ECG).

Material/Methods

This prospective study was a self-controlled case series study that recruited 116 female patients with osteoporosis. The patients underwent standard 12-lead electrocardiography before and 1 day after zoledronic acid intravenous infusion to evaluate cardiac adverse effects and the change in ECG parameters after the infusion. Heart rhythm, atrial and ventricular premature contractions, atrial fibrillation, P wave, and QTc parameters were measured using an ECG. A blood biochemical examination was performed for all patients before the ZA infusion. Body temperature was measured twice per day.

Results

Before ZA administration, ECG findings were normal in 47 patients and abnormal in 69 patients. After ZA administration, ECG findings were normal in 35 patients and abnormal in 81 patients. New onsets of premature atrial contractions and atrial fibrillation were observed in 1 patient each, and new onsets of premature ventricular contractions were observed in 2 patients. The heart rate was obviously higher, and the QT interval was obviously shorter after ZA administration, compared with before administration. No significant differences in P wave and QTc parameters were found between the 2 ECG measurements.

Conclusions

During the acute phase, 116 women with osteoporosis who were treated with zoledronic acid infusion did not develop significantly abnormal ECG changes.

Inhibition of Lipoxygenases Showed No Benefit for the Musculoskeletal System in Estrogen Deficient Rats

BACKGROUND

In previous studies, we reported the beneficial impact of two lipoxygenase-inhibitors, Baicalein and Zileuton, on osteoporotic bone in a postmenopausal rat model. Whereas subcutaneous Baicalein predominantly improved cortical bone, Zileuton enhanced vertebral and femoral trabecular bone. In this study, we aimed to reveal whether the oral administration of Baicalein caused similar effects on bone and whether a combined administration of Baicalein and Zileuton could act synergistically to ameliorate the formerly reported effects in the musculoskeletal system.

METHODS

We treated ovariectomized (OVX) female Sprague-Dawley rats either with Baicalein (10mg/kg BW), Zileuton (10mg/kg BW) or a combination of both (each 10mg/kg BW) for 13 weeks and compared with untreated OVX and NON-OVX groups (n=12-16 rats per group). Lumbar vertebral bodies and femora were analyzed. Tibiae were osteotomized, plate-stabilized (at week 8 after OVX) and likewise analyzed by biomechanical, histological, micro-computed tomographical and ashing tests. The skeletal muscle structure was analyzed.

RESULTS

Oral administration of Baicalein did not confirm the reported favorable cortical effects in neither vertebra nor femur. Zileuton showed a beneficial effect on trabecular vertebra, while the femur was negatively affected. Callus formation was enhanced by all treatments; however, its density and biomechanical properties were unaltered. Lipoxygenase inhibition did not show a beneficial effect on skeletal muscle. The combination therapy did not ameliorate OVX-induced osteoporosis but induced even more bone loss.

CONCLUSIONS

The preventive anti-osteoporotic treatments with two lipoxygenase inhibitors applied either alone or in combination showed no benefit for the musculoskeletal system in estrogen deficient rats.

Gradual, but Not Sudden, Dose-Dependent Increase of ONJ Risk With Bisphosphonate Exposure: A Nationwide Cohort Study in Women With Osteoporosis

BACKGROUND

A causal relationship of bisphosphonate (BP) exposure with osteonecrosis of the jaw (ONJ) has been reported; however, a definite dose-dependent risk remains to be elucidated beyond current vague recommendations of 4-year oral BP for ONJ risk increase.

OBJECTIVE

To identify the effect of bisphosphonate cumulative dose on ONJ development in women with osteoporosis.

METHODS

A retrospective cohort study was designed using the National Health Insurance Service-National Health Screening database of Korea. Females over the age of 50 were diagnosed with osteoporosis based on the International Classification of Diseases 10th revision (ICD-10) codes (M80, M81, and M82) with bisphosphonate prescriptions. The cumulative dose of bisphosphonate was calculated using defined daily doses (DDD) to provide an accurate BP cumulative effect on ONJ occurrence. Osteonecrosis of the jaw was identified using both ICD-10 codes and related procedure codes. The incidence rates of ONJ and hazard ratios were estimated according to the bisphosphonate cumulative dose.

RESULTS

Among 74,491 included subjects, 190 cases of ONJ were identified. The incidence rate substantially increased after BP cumulative dose over 1 year (25.75 for DDD < 365, which increased to 53.43 for 365 ≤ DDD < 730). Compared to subjects with a cumulative dose of DDD < 365, subjects with a cumulative dose of 365 ≤ DDD < 730 had 2.36-fold hazard for developing ONJ (p < 0.001).

CONCLUSION

A bisphosphonate cumulative dose of more than 1 year had an increased risk of ONJ development. A gradual, but not sudden, dose-dependent increase in ONJ risk with BP exposure needs to be considered in providing the optimal BP treatment duration.

Long-Term Effects of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass on Body Composition and Bone Mass Density

BACKGROUND

Currently, the two most common bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Long-term data comparing the two interventions in terms of their effect on body composition and bone mass density (BMD) are scarce.

OBJECTIVE

The aim of this study was to assess body composition and BMD at least 5 years after LSG and LRYGB.

SETTING

Department of Endocrinology and Nutrition, St. Claraspital Basel and St. Clara Research Ltd., Basel, Switzerland.

METHODS

Bariatric patients at least 5 years after surgery (LSG or LRYGB) were recruited, and body composition and BMD were measured by means of dual-energy X-ray absorptiometry. Data from body composition before surgery were included in the analysis. Blood samples were taken for determination of plasma calcium, parathyroid hormone, vitamin D3, alkaline phosphatase, and C-terminal telopeptide, and the individual risk for osteoporotic fracture assessed by the Fracture Risk Assessment Tool score was calculated. After surgery, all patients received multivitamins, vitamin D3, and zinc. In addition, LRYGB patients were prescribed calcium.

RESULTS

A total of 142 patients were included, 72 LSG and 70 LRYGB, before surgery: median body mass index 43.1, median age 45.5 years, 62.7% females. Follow-up after a median of 6.7 years. For LRYGB, the percentage total weight loss at follow-up was 26.3% and for LSG 24.1% (p = 0.243). LRYGB led to a slightly lower fat percentage in body composition. At follow-up, 45% of both groups had a T score at the femoral neck below -1, indicating osteopenia. No clinically relevant difference in BMD was found between the groups.

CONCLUSIONS

At 6.7 years after surgery, no difference in body composition and BMD between LRYGB and LSG was found. Deficiencies and bone loss remain an issue after both interventions and should be monitored.

Bacteroides vulgatus diminishes colonic microbiota dysbiosis ameliorating lumbar bone loss in ovariectomized mice

There is a need to discover additional kinds of intestinal microbiota to supplement the probiotic-treatment of postmenopausal osteoporosis. Increasing evidence has indicated that Bacteroides vulgatus has potential as a probiotic for ameliorating postmenopausal bone loss. In this study, ovariectomized female C57/BL6 mice were treated with B. vulgatus ATCC 8482 gavage to investigate the differences in colonic microbiota composition, inflammation signal pathways, inflammatory cytokines, bone turnover markers, and lumbar vertebrae microstructure compared with the control group. Our results show that B. vulgatus ATCC 8482 diminished microbiota dysbiosis and subsequently down-regulated the colonic lipopolysaccharide/TLR-4/p-NF-κB pathway leading to decreased serum TNF-α. This reduced TNF-α/RANKL expression and induced ALP and Runx-2 expression in the 5th lumbar vertebra, leading to amelioration of bone loss and microstructure destruction in the lumbar vertebra of ovariectomized mice. Taken together, these results indicate that B. vulgatus could be a probiotic for treatment of postmenopausal lumbar osteoporosis.

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.

Fecal and Serum Metabolomic Signatures and Microbial Community Profiling of Postmenopausal Osteoporosis Mice Model

Background

Multiple studies have shown that an imbalance in the intestinal microbiota is related to bone metabolism, but the role of the intestinal microbiota in postmenopausal osteoporosis remains to be elucidated. We explored the effect of the intestinal microbiota on osteoporosis.

Methods

We constructed a postmenopausal osteoporosis mouse model, and Micro CT was used to observe changes in bone structure. Then, we identified the abundance of intestinal microbiota by 16S RNA sequencing and found that the ratio of Firmicutes and Bacteroidetes increased significantly. UHPLC-MS analysis was further used to analyze changes in metabolites in feces and serum.

Results

We identified 53 upregulated and 61 downregulated metabolites in feces and 2 upregulated and 22 downregulated metabolites in serum under OP conditions, and interestedly, one group of bile acids showed significant differences in the OP and control groups. Network analysis also found that these bile acids had a strong relationship with the same family, Eggerthellaceae. Random forest analysis confirmed the effectiveness of the serum and fecal models in distinguishing the OP group from the control group.

Conclusions

These results indicated that changes in the gut microbiota and metabolites in feces and serum were responsible for the occurrence and development of postmenopausal osteoporosis. The gut microbiota is a vital inducer of osteoporosis and could regulate the pathogenesis process through the “microbiota-gut-metabolite-bone” axis, and some components of this axis are potential biomarkers, providing a new entry point for the future study on the pathogenesis of postmenopausal osteoporosis.

Disordered metabolism in mice lacking irisin

Irisin is a product of fibronectin type III domain-containing protein (Fndc5) and is involved in the regulation of adipokine secretion and the differentiation of osteoblasts and osteoclasts. In this study, we aimed to determine whether irisin lacking affects glucose/lipid and bone metabolism. We knocked out the Fndc5 gene to generate irisin-lacking mice. Remarkable, irisin lacking was related to poor 'browning response', with a bigger size of the intraperitoneal white adipose cell and decreased a number of brown adipose cells in brown adipose of interscapular tissue. The irisin lacking mice had hyperlipidemia and insulin resistance, reduced HDL-cholesterol level, increased LDL-cholesterol level, and decreased insulin sensitivity. The lacking of irisin was associated with reduced bone strength and bone mass in mice. The increased number of osteoclasts and higher expression of RANKL indicated increased bone resorption in irisin lacking mice. The level of IL-6 and TNF-α also increased in irisin lacking mice. The results showed that irisin lacking was related to decreased 'browning response', glucose/lipid metabolic derangement, and reduced bone mass with increased bone resorption. Further studies are needed to confirm these initial observations and explore the mechanisms underlying the effects of irisin on glucose/lipid and bone metabolism.

Therapeutic Dimensions of Bisphosphonates: A Clinical Update

Bisphosphonates (BPs) are a commonly used class of drugs for the treatment of bone disorders. An extensive review of BPs with their clinical efficacy and safety profile is unavailable. This study aimed to review the available literature on BPs, summarize their role in clinical therapy, and emphasize their safety profile. Authors reviewed the existing literature using the Google Scholar, PubMed, and Micromedex databases and analyzed the collected articles. BPs are the preferred medication for osteoporosis and other similar conditions owing to their efficient antiosteoclastic activity. Few of them are available in oral dosage forms; hence, they are patient-friendly. The mechanism of action, common adverse effects and their clinical applications, precautions and warnings pertaining to the route of administration, and safety profiles have been discussed in this manuscript. The common adverse effects are majorly related to the gastrointestinal, cardiovascular, and endocrine system. Upon chronic usage, patients may experience serious problems like osteonecrosis of the jaw and atypical bone fractures. Although BPs are effective and safe, they may cause GI adverse effects and rare cases of osteonecrosis. Patient counseling could prove beneficial in early identification and prevention of the adverse effects associated with BPs.

Advanced 2D image processing technique to predict hip fracture risk in an older population based on single DXA scans

A new technique to enhance hip fracture risk prediction in older adults was presented and assessed. The new method dramatically improved prediction at high specificity levels using only a standard clinical diagnostic scan. This has the potential to be implemented in clinical practice to enhance patient fragility diagnosis.

INTRODUCTION

Diagnosis of osteoporosis is based on the measurement of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA) scans. However, studies have shown this to be insufficient to accurately predict hip fractures. Therefore, complementary methods are needed to enhance hip fracture risk prediction to identify vulnerable patients.

METHODS

Hip DXA scans were obtained for 192 subjects from the Canadian Multicenter Osteoporosis Study (CaMos), 50 of whom had experienced a hip fracture within 5 years of the scan. 2D statistical shape and appearance modeling was performed to account for the effect of the femur's geometry and BMD distribution on hip fracture risk. Statistical shape modeling (SSM), and statistical appearance modeling (SAM) were also used separately to predict the fracture risk based solely on the femur's geometry and BMD distribution, respectively. Combined with BMD, age, and body mass index (BMI), logistic regression was performed to estimate the fracture risk over the 5-year period.

RESULTS

Using the new technique, hip fractures were correctly predicted in 78% of cases compared with 36% when using the T-score. The accuracy of the prediction was not greatly reduced when using SSM and SAM (78% and 74% correct, respectively). Various geometric and BMD distribution traits were identified in the fractured and non-fractured groups.

CONCLUSION

2D SSAM can dramatically improve hip fracture prediction at high specificity levels and estimate the year of the impending fracture using standard clinical images. This has the potential to be implemented in clinical practice to estimate hip fracture risk.

Promising application of Pulsed Electromagnetic Fields (PEMFs) in musculoskeletal disorders

Increasing evidence suggests that an exogenous electromagnetic field might be involved in many biologic processes which are of great importance for therapeutic interventions. Pulsed electromagnetic fields (PEMFs) are known to be a noninvasive, safe and effective therapy agent without apparent side effects. Numerous studies have shown that PEMFs possess the potential to become a stand-alone or adjunctive treatment modality for treating musculoskeletal disorders. However, several issues remain unresolved. Prior to their widely clinical application, further researches from well-designed, high-quality studies are still required to standardize the treatment parameters and derive the optimal protocol for health-care decision making. In this review, we aim to provide current evidence on the mechanism of action, clinical applications, and controversies of PEMFs in musculoskeletal disorders.

Bone health assessment in clinical practice is infrequenty performed in patients with chronic pancreatitis

BACKGROUND

Chronic pancreatitis (CP) patients have a high prevalence of osteoporotic fractures. In addition to prevalence of osteoporotic fractures, we evaluated how often bone health is assessed by dual-energy x-ray absorptiometry (DXA) in clinical practice, and the performance of Fracture Risk Assessment Tool (FRAX®) in predicting fracture risk in CP patients.

METHODS

Medical records of CP patients age ≥40 years prospectively enrolled in the North American Pancreatitis Study 2 (NAPS2) from the University of Pittsburgh Medical Center from 2000 to 2014 were retrospectively reviewed to gather additional relevant data before, at, and after enrollment until December 2016. We determined if patients underwent DXA, compared their observed prevalence of fractures with published data from two large US studies based on administrative data, and their predicted fracture risk with US population based on FRAX®.

RESULTS

Only 21% (49/239) patients were evaluated by DXA during their care. The observed cumulative prevalence of fragility fractures in NAPS2 CP patients (9.2%, 95% confidence interval 5.9-13.6) was significantly greater than in controls (1.46% and 2.16%, p ≤ 0.001 for each comparison) and CP patients (4.66%, and 5.13%, p < 0.005 for each comparison) in the two US administrative data studies. The FRAX® 10-year probability of major osteoporotic fracture of ≥20% (5.1% vs. 8.3%, p > 0.05) and for hip fracture of ≥3% (19.6% vs. 18.9%, p > 0.05) in NAPS2 CP patients did not differ from the US population.

CONCLUSIONS

Despite their high risk of fragility fractures, bone health is infrequently assessed in CP patients. FRAX® may not adequately predict fracture risk in CP patients.

Gut microbiome and osteoporosis: a review

Osteoporosis (OP) is a chronic metabolic bone disease characterized by the decrease of bone tissue per unit volume under the combined action of genetic and environmental factors, which leads to the decrease of bone strength, makes the bone brittle, and raises the possibility of bone fracture. However, the exact mechanism that determines the progression of OP remains to be underlined. There are hundreds of trillions of symbiotic bacteria living in the human gut, which have a mutually beneficial symbiotic relationship with the human body that helps to maintain human health. With the development of modern high-throughput sequencing (HTS) platforms, there has been growing evidence that the gut microbiome may play an important role in the programming of bone metabolism. In the present review, we discuss the potential mechanisms of the gut microbiome in the development of OP, such as alterations of bone metabolism, bone mineral absorption, and immune regulation. The potential of gut microbiome-targeted strategies in the prevention and treatment of OP was also evaluated.

Cite this article: Bone Joint Res 2020;9(8):524–530.

Primary Hyperparathyroidism: Experience from a Tertiary Care Centre in Pakistan

Objective:

To study the clinical, biochemical and radiological features and management outcomes of patients with primary hyperparathyroidism.

Methods:

This retrospective study was conducted at the Aga Khan University Hospital, Karachi, Pakistan and comprised data of patients with primary hyperparathyroidism from 2008 to 2017.

Results:

Out of 103 patients, 83(80.6%) were female. Overall mean age was 59.3±16.2 years. Musculoskeletal manifestations were seen in 60(58.3%) patients and renal manifestations in 28(27.2%). Ostieits fibrosa cystica was found in 04(3.88%) patients. Overall, Ultrasound neck and sestamibi scan localized the lesion in 66 (64.1%) and 77 (76.2%) patients respectively. Among 79 patients who underwent surgery, 67 (84.8%) patients had an adenoma, 05 (6.3%) had hyperplasia and 02(2.53%) patients had parathyroid carcinoma whereas histopathology was inconclusive in 5 (6.32%) out of the 79 surgically treated patients. Disease recurrence was seen in 13 out of 79(16.45%) patients who underwent surgery.

Conclusion:

Primary hyperparathyroidism is associated with significant morbidity in our population. Targeted measures like improving patient awareness, routine calcium screening, vitamin D supplementation and a high index of suspicion by the clinician may help in early diagnosis of the condition and thus reduce morbidity.

The effectiveness and cost-effectiveness of an integrated osteoporosis care programme for postmenopausal women in Flanders: study protocol of a quasi-experimental controlled design

Osteoporosis causes high individual and societal burden, due to limited attention to fracture prevention. Integrated care for chronic conditions has shown to facilitate management of these conditions, improving clinical outcomes alongside quality of life and cost-effectiveness. This manuscript describes an integrated osteoporosis care programme that will be implemented in primary care.

OBJECTIVE

To provide a comprehensive description of a quasi-experimental study design in which a newly developed integrated osteoporosis care (IOC) programme for the management of postmenopausal osteoporosis (PO) in primary care (PC) is implemented and will be compared with care as usual (CAU).

METHODS

A literature research was performed and expert meetings have been taking place, which has led to the development of a complex PC intervention based on framework for integrated people-centred health services (IPCHS).

RESULTS

This manuscript describes the developmental process of the preclinical phase of a quasi-experimental real-world design and the interventions as a result of this process that will be implemented during the clinical phase, along with the evaluation that will take place alongside the clinical phase: An integrative approach for the management of PO in primary care was developed and will be implemented in greater region of Ghent (GRG), Belgium. The approach consists of a complex intervention targeting patients and PC stakeholders in osteoporosis care (e.g. general practitioners (GPs), physiotherapists, nurses, pharmacists). A comparison will be made with CAU using medication possession ratios (MPR) of included patients as primary outcome. These data will be obtained from the national health database. Secondary outcomes are physician outcomes, patient-reported outcome measures (PROMs), and patient-reported experience measures (PREMs). A cost-effectiveness evaluation will be performed if the programme appears to be effective in terms of MPR.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03970902.

Medication-Related Osteonecrosis of the Jaws

Medication-related osteonecrosis of the jaw is an oral complication in cancer patients being treated with either antiresorptive or antiangiogenic drugs. The first reports of MRONJ were published in 2003. Hundreds of manuscripts have been published in the medical and dental literature describing the complication, clinical and radiographic signs and symptoms, possible pathophysiology, and management. Despite this extensive literature, the pathobiological mechanisms by which medication-related osteonecrosis of the jaw develops have not yet been fully delineated. The aim of this manuscript is to present current knowledge about the complication ragarding to the definition, known risk factors, and clinical management recommendations. Based on this current state of the science, we also propose research directions that have potential to enhance the management of future oncology patients who are receiving these agents.

Circulating miRNAs: A New Opportunity in Bone Fragility

Osteoporosis, one of the leading causes of bone fractures, is characterized by low bone mass and structural deterioration of bone tissue, which are associated with a consequent increase in bone fragility and predisposition to fracture. Current screening tools are limited in estimating the proper assessment of fracture risk, highlighting the need to discover novel more suitable biomarkers. Genetic and environmental factors are both implicated in this disease. Increasing evidence suggests that epigenetics and, in particular, miRNAs, may represent a link between these factors and an increase of fracture risk. miRNAs are a class of small noncoding RNAs that negatively regulate gene expression. In the last decade, several miRNAs have been associated with the development of osteoporosis and bone fracture risk, opening up new possibilities in precision medicine. Recently, these molecules have been identified in several biological fluids, and the possible existence of a circulating miRNA (c-miRNA) signature years before the fracture occurrence is suggested. The aim of this review is to provide an overview of the c-miRNAs suggested as promising biomarkers for osteoporosis up until now, which could be helpful for early diagnosis and monitoring of treatment response, as well as fracture risk assessment, in osteoporotic patients.

Neuropeptides are associated with pain threshold and bone microstructure in ovariectomized rats

OBJECTIVES

Postmenopausal osteoporosis (PMO) is a metabolic skeletal disorder with impaired bone density and bone quality in postmenopausal women. The aim of the present study was to investigate the correlation between neuropeptides, bone microstructure and pain threshold in ovariectomized (OVX) rats.

METHODS

Female rats were randomly divided into the ovariectomized (OVX) group and the sham surgery (SHAM) group. Bone microstructure and immunocytochemistry for substance P (SP), calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY) in tibial and DRG were performed. Pain threshold was assessed at post-operative 11 weeks. Pearson correlation coefficients were calculated between neuropeptides, bone microstructure and pain threshold.

RESULTS

Significant decreases in bone volume fraction (BV/TV) and trabecular number (Tb. N) but significant increases in trabecular spacing (Tb.Sp) were showed in OVX group. Mechanical pain threshold (MPT) in OVX group was significantly decreased. The MOD values for SP, CGRP and VIP of tibial in OVX group were significantly lower, whereas NPY, NPY1R and NPY2R were significantly higher. And SP, CGRP, VIP, NPY and NPY2R of DRG were significantly increased in OVX group, while NPY1R was significantly decreased. Correlation analysis showed that NPY, Y1R and Y2R in bone were negatively correlated with BV/TV. MPT was negatively correlated with NPY and Y2R in DRG, and positively correlated with Y1R in DRG.

CONCLUSIONS

Our results suggested that SP, CGRP, VIP and NPY were involved in the osteoporotic bone microstructure and mechanical hypersensitivity in OVX rats, indicating the potential to utilize neuropeptides as novel therapeutic targets for PMO.

Calcium Bioavailability of Opuntia ficus-indica Cladodes in an Ovariectomized Rat Model of Postmenopausal Bone Loss

Osteoporosis is a disease of the skeletal system characterized by low bone mass and bone weakening, which increase the risk of fracture. This disease is associated with menopause because hypoestrogenism induces the maturation and activation of osteoclasts. In addition, a low dietary intake of calcium leads to low bone mineral density and postmenopausal osteoporosis. The objectives of this work were to determine calcium bioavailability of Opuntia ficus-indica cladodes at a late maturity stage and to assess its contribution in improving bone health in an ovariectomized rat model. Two-month-old Wistar female rats (n = 35) were used and distributed in seven experimental groups: (i) control group (Crtl), (ii) sham group (SH), (iii) ovariectomized group (OVX), (iv) ovariectomized group supplemented with calcium citrate (CCa), (v) ovariectomized group supplemented with O. ficus-indica powder (NI), (vi) ovariectomized group supplemented with soluble fiber from O. ficus-indica (FS) and (vii) ovariectomized group supplemented with insoluble fiber from O. ficus-indica (FI). Our results showed that calcium in the soluble fiber of O. ficus-indica is bioavailable and contributes to improve the physical, densitometric, biomechanical and microstructural properties of bones in ovariectomized rats. These findings indicated that O. ficus-indica cladodes at a late maturity stage represent a good source of bioavailable calcium and consumption of these cladodes might be beneficial for the prevention of osteoporosis and other bone diseases.