Christensen House: A Case Study for Inclusive Decision-making within Professional Associations

Accounts of dental history in Queensland are few and almost invariably authored by those who either held or hold power. The focus is 'who, what, when' rather than 'why and how'. House-related developments as a case study provide an opportunity to assess aspects of the Australian Dental Association Queensland Branch's (ADAQ) model of administration in the early 1970s. The authors use literature review and historical methods. The ADAQ's articles of association, codes of conduct and memoranda centralized Brisbane-based authority and elite leadership into its management. The ADAQ council's decision to build Christensen House in Brisbane, prompted by the posthumous benevolence of George Christensen, was informed, logical, measured and appeared timely. The advocates for the house were innovative, optimistic, resolute, and well-intentioned, with their design and selected location of the building being appropriate. However, the decision occurred at a time of latent discontent within the membership, many of whom did not support the project financially. Distance in Queensland dictates that provincial members either accept or tolerate Brisbane-based centralized authority within ADAQ administration. Nonetheless, when it comes to policy warranting membership subscription, the Christensen House experience demonstrates that the modus operandi of the ADAQ council should be, as far as possible, inclusive, and representative.

Incremental costs of fragility fractures: a population-based matched -cohort study from Ontario, Canada

Using a matched cohort design, the 1-year excess cost of incident fragility fractures at any site was $26,341 per patient, with 43% of total excess costs attributed to hospitalization. The high economic burden of fractures in Ontario underscores the urgency of closing the secondary fracture prevention gap.

INTRODUCTION

This retrospective real-world observational study was conducted to document the incremental costs associated with fragility fractures in Ontario, Canada.

METHODS

Patients aged >65 years with an index fragility fracture occurring between January 2011 and March 2015 were identified from administrative databases and matched 1:1 to a cohort of similar patients without a fracture. Healthcare resource utilization data were extracted from healthcare records and associated costs were calculated on a per-patient level and for the province of Ontario. Costs were presented as 2017 Canadian dollars.

RESULTS

The eligible cohort included 115,776 patients with a fragility fracture. Of these, 101,773 patients were successfully matched 1:1 to a non-fracture cohort. Overall, hip fractures (n = 31,613) were the most common, whereas femur fractures (n = 3002) were the least common type. Hospitalization and continuing care/home care/long-term care accounted for more than 60% of 1-year direct costs, whereas 5% was attributed to medication costs. First-year costs per patient in the fracture cohort were approximately threefold higher versus the non-fracture cohort (mean $37,362 versus $11,020, respectively). The incremental first-year direct healthcare costs of fragility fractures for the province of Ontario were calculated at $724 million per year.

CONCLUSIONS

Fragility fractures were associated with a threefold increase in overall mean healthcare costs per patient compared to patients without fractures. With an aging population, there is an urgent need for improved prevention strategies for patients at high-risk of fracture to decrease the economic burden of fragility fractures on the Canadian healthcare system.

Impact of COVID-19 on the Mental Health and Well-Being of Latinx Caregivers of Children with Intellectual and Developmental Disabilities

The COVID-19 pandemic has impacted the entire world in unprecedented ways. However, populations that have had a history of marginalization have experienced a more profound impact. One such group is Latinx families of children with intellectual and developmental disabilities (IDD) in the Unites States. In this study, we used a mixed methods approach to explore the impact of the pandemic on the mental health and well-being of Latinx caregivers of children with IDD. Specifically, we (1) identified which social determinants of health are correlated with maternal caregivers perceived general health, mental health, and well-being; (2) explored the impact of the pandemic on families' overall eating and physical activity routines; and (3) identified emergent themes from caregivers' experiences during the pandemic. Thirty-seven Latinx caregivers participated in three interviews in which several validated instruments were administered. The results indicated that perceived social support, annual family income, food security, and receipt of financial benefits were correlated with fewer depressive symptoms. Annual family income was also significantly correlated with perceived general health. Most caregivers reported that the pandemic had placed a strain on their economic situation; increased their isolation; and disrupted their child's therapeutic supports, online education, eating routines, and engagement in physical activity. Meanwhile, some caregivers reported positive changes as a result of the pandemic. Implications for future research and practice are discussed.

Simulated effects of early menopausal bone mineral density preservation on long-term fracture risk: a feasibility study

Prevention of early menopausal bone loss may reduce the future burden of osteoporosis. In this modelling exercise, an osteoporosis prevention strategy involving 5-year infusions of zoledronic acid, beginning early in menopause, reduced long-term fracture risk and the proportion of aging women with femoral neck densitometric osteoporosis. This strategy warrants further evaluation.

INTRODUCTION

Preventing early menopausal bone loss may substantially reduce the future burden of osteoporosis. We modelled the effects of infrequent zoledronic acid infusions on long-term fracture risk.

METHODS

Data from the Canadian Multicentre Osteoporosis Study (CaMos) were used to determine the expected natural history of femoral neck areal bone mineral density (BMD) and fracture risk (using FRAX®) from ages 50-80 for women with no antiresorptive drug exposures. We modelled the effects of three infusions of zoledronic acid (at ages 50, 55, 60) on long-term fracture risk, assuming this intervention would preserve BMD until age 65 years, followed by losses mirroring early menopausal BMD loss.

RESULTS

At age 65, untreated women and zoledronic acid recipients had expected mean (SD) femoral neck T-scores of - 1.5(1.0) and - 0.8(1.0), 10-year major osteoporotic fracture (MOF) risks of 9.8%(5.0) and 8.0%(3.7) and hip fracture risks of 1.7%(2.4) and 0.8%(1.2), respectively. At age 80, untreated women and zoledronic acid recipients had expected femoral neck T-scores of - 1.9(0.9) and - 1.4(0.9), MOF risks of 17.9%(8.2) and 14.9%(6.4) and hip fracture risks of 6.3%(6.2) and 4.4%(4.5), respectively. The expected proportion of women with femoral neck T-score ≤ - 2.5 was 14.9% for untreated women and 3.8% for zoledronic acid recipients at age 65, increasing to 28.1% and 12.0%, respectively, at age 80. Numbers-needed-to-treat to prevent one case of densitometric osteoporosis were 9 at age 65 and 5 at age 80.

CONCLUSION

Infrequent infusions of zoledronic acid, initiated early in menopause, are expected to reduce long-term fracture risk and result in a substantial reduction in the proportion of women with densitometric osteoporosis after age 65.

A scorecard for osteoporosis in Canada and seven Canadian provinces

The scorecard evaluates the burden and management of osteoporosis in Canada and how care pathways differ across Canadian provinces. The results showed there are inequities in patients' access to diagnosis, treatment, and post-fracture care programs in Canada. Interventions are needed to close the osteoporosis treatment gap and minimize these inequities.

INTRODUCTION

The purpose of this study was to develop a visual scorecard that assesses the burden of osteoporosis and its management within Canada and seven Canadian provinces.

METHODS

We adapted the Scorecard for Osteoporosis in Europe (SCOPE) to score osteoporosis indicators for Canada and seven provinces (British Columbia, Alberta, Saskatchewan, Ontario, Quebec, New Brunswick, and Newfoundland). We obtained data from a comprehensive literature review and interviews with osteoporosis experts. We scored 20 elements across four domains: burden of disease, policy framework, service provision, and service uptake. Each element was scored as red, yellow, or green, indicating high, intermediate, or low risk, respectively. Elements with insufficient data were scored black.

RESULTS

Canada performed well on several elements of osteoporosis care, including high uptake of risk assessment algorithms and minimal wait times for hip fracture surgery. However, there were no established fracture registries, and reporting on individuals with high fracture risk who remain untreated was limited. Furthermore, osteoporosis was not an official health priority in most provinces. Government-backed action plans and other osteoporosis initiatives were primarily confined to Ontario and Alberta. Several provinces (Saskatchewan, New Brunswick, Newfoundland) did not have any registered fracture liaison service (FLS) programs. Access to diagnosis and treatment was also inconsistent and reimbursement policies did not align with clinical guidelines.

CONCLUSION

Government-backed action plans are needed to address provincial inequities in patients' access to diagnosis, treatment, and FLS programs in Canada. Further characterization of the treatment gap and the establishment of fracture registries are critical next steps in providing high-quality osteoporosis care.

A single dose of zoledronate preserves bone mineral density for up to 2 years after a second course of romosozumab

This phase 2 study evaluated the efficacy and safety of transitioning to zoledronate following romosozumab treatment in postmenopausal women with low bone mass. A single dose of 5 mg zoledronate generally maintained the robust BMD gains accrued with romosozumab treatment and was well tolerated.

INTRODUCTION

Follow-on therapy with an antiresorptive agent is necessary to maintain the skeletal benefits of romosozumab therapy. We evaluated the use of zoledronate following romosozumab treatment.

METHODS

This phase 2, dose-finding study enrolled postmenopausal women with low bone mineral density (BMD). Subjects who received various romosozumab doses or placebo from months 0-24 were rerandomized to denosumab (60 mg SC Q6M) or placebo for 12 months, followed by open-label romosozumab (210 mg QM) for 12 months. At month 48, subjects who had received active treatment for 48 months were assigned to no further active treatment and all other subjects were assigned to zoledronate 5 mg IV. Efficacy (BMD, P1NP, and β-CTX) and safety were evaluated for 24 months, up to month 72.

RESULTS

A total of 141 subjects entered the month 48-72 period, with 51 in the no further active treatment group and 90 in the zoledronate group. In subjects receiving no further active treatment, lumbar spine (LS) BMD decreased by 10.8% from months 48-72 but remained 4.2% above the original baseline. In subjects receiving zoledronate, LS BMD was maintained (percentage changes: - 0.8% from months 48-72; 12.8% from months 0-72). Similar patterns were observed for proximal femur BMD in both groups. With no further active treatment, P1NP and β-CTX decreased but remained above baseline at month 72. Following zoledronate, P1NP and β-CTX levels initially decreased but approached baseline by month 72. No new safety signals were observed.

CONCLUSION

A zoledronate follow-on regimen can maintain robust BMD gains achieved with romosozumab treatment.

Evaluation of Chemical Effects on Network Formation in Cortical Neurons Grown on Microelectrode Arrays

Thousands of chemicals to which humans are potentially exposed have not been evaluated for potential developmental neurotoxicity (DNT), driving efforts to develop a battery of in vitro screening approaches for DNT hazard. Here, 136 unique chemicals were evaluated for potential DNT hazard using a network formation assay (NFA) in cortical cells grown on microelectrode arrays. The effects of chemical exposure from 2 h postplating through 12 days in vitro (DIV) on network formation were evaluated at DIV 5, 7, 9, and 12, with cell viability assessed at DIV 12. Only 82 chemicals altered at least 1 network development parameter. Assay results were reproducible; 10 chemicals tested as biological replicates yielded qualitative results that were 100% concordant, with consistent potency values. Toxicological tipping points were determined for 58 chemicals and were similar to or lower than the lowest 50% effect concentrations (EC50) for all parameters. When EC50 and tipping point values from the NFA were compared to the range of potencies observed in ToxCast assays, the NFA EC50 values were less than the lower quartile for ToxCast assay potencies for a subset of chemicals, many of which are acutely neurotoxic in vivo. For 13 chemicals with available in vivo DNT data, estimated administered equivalent doses based on NFA results were similar to or lower than administered doses in vivo. Collectively, these results indicate that the NFA is sensitive to chemicals acting on nervous system function and will be a valuable contribution to an in vitro DNT screening battery.

James Meyrick Croker: A Model for Professional Behavior

The rationale that underpins volunteering has long fascinated behavioral scientists. James Meyrick Croker's personal life, professional career and community engagement conform to the classic twentieth century model for professional behavior. Accordingly, the authors use historical methods of investigation to evaluate the influences on and the legacies from a remarkable contribution to the professions and the community. The narrative demonstrates elements of altruism, collaboration, conviction, compassion, drive, entrepreneurialism, familial and grammar school influence, leadership, pragmatism and vision. Croker's professional and community service was multi-organizational. Concurrent demands on his time warranted discipline, energy and expertise. For the behavioral scientist, achievement, affiliation, nature and nurture appear relevant to the outcome. Available archives provide no evidence of ego-driven motivation. Leadership style was transformational not transactional. Major legacies to the national and state Australian Dental Associations are ADAQ Christensen House (1972-1980), the eventual financial stability for the Australian Dental Association Queensland Branch, formal dental assistant training, policies of the Australian and Queensland Councils of Professions, a notable Goddard Oration and the successful 24th Australian Dental Congress.

Efficacy and safety of denosumab vs. bisphosphonates in postmenopausal women previously treated with oral bisphosphonates

Transitioning postmenopausal women with osteoporosis from a bisphosphonate to denosumab appears to be safe and more effective at improving BMD than continuing treatment with a bisphosphonate.

INTRODUCTION

We conducted a patient-level pooled analysis of four studies to estimate the efficacy and safety of transitioning to denosumab vs. continuing bisphosphonate treatment in postmenopausal women who previously received oral bisphosphonates.

METHODS

Patients received 60 mg denosumab once every 6 months or a bisphosphonate (oral alendronate, risedronate, ibandronate, or intravenous zoledronic acid). Endpoints were change from baseline in lumbar spine, total hip, femoral neck, and 1/3 radius BMD at month 12, change from baseline in serum CTX-1 and P1NP, and incidence of adverse events.

RESULTS

A total of 2850 randomized patients (1424 bisphosphonate:1426 denosumab) were included in the analysis. Percentage change in BMD was significantly greater (p < 0.001) for denosumab vs. bisphosphonate at each skeletal site; differences in BMD changes ranged from 0.6 to 2.0%. Percentage decrease in serum CTX-1 and P1NP was significantly greater (p < 0.0001) for denosumab vs. bisphosphonate at months 1, 6, and 12; in the denosumab group only, percentage change in serum CTX-1 at month 1 was significantly correlated with percentage change in lumbar spine and total hip BMD at month 12. The incidences of adverse events were similar between treatment groups. Three patients (one bisphosphonate and two denosumab) had atypical femoral fractures, all from the denosumab vs. zoledronic acid study.

CONCLUSION

Postmenopausal women can safely transition from a bisphosphonate to denosumab, which is more effective at improving BMD than continuing with a bisphosphonate.

CLINICAL TRIALS REGISTRATION

NCT00377819, NCT00919711, NCT00936897, NCT01732770.

Long-term denosumab treatment restores cortical bone loss and reduces fracture risk at the forearm and humerus: analyses from the FREEDOM Extension cross-over group

Upper limb fractures (including wrist, forearm, and humerus) represent a significant burden among postmenopausal women with osteoporosis. Up to 7 years of treatment with denosumab resulted in an increase in bone mineral density and decrease in fractures in upper limb sites.

INTRODUCTION

Upper limb (wrist, forearm, and humerus) fractures are a significant burden in osteoporosis, associated with significant morbidity and mortality. Denosumab, a monoclonal antibody against RANK ligand, increases bone mineral density (BMD) and decreases vertebral, nonvertebral, and hip fractures. Here, we evaluated the long-term effect of denosumab treatment on upper limb fracture risk and BMD.

METHODS

In the FREEDOM trial, subjects were randomized 1:1 to receive every-6-month denosumab 60 mg or placebo subcutaneously for 3 years, after which all subjects could receive denosumab for up to 7 years (Extension). Among placebo subjects who completed FREEDOM and enrolled in the Extension, wrist, forearm, humerus, and upper limb fracture rates and rate ratios between different time periods (FREEDOM years 1-3, Extension years 1-3, and Extension years 4-7) were computed. BMD at the ultradistal radius, 1/3 radius, and total radius was analyzed in a subset of subjects in a BMD substudy.

RESULTS

This analysis included 2207 subjects (116 in the BMD substudy). Fracture rates decreased over the 7-year Extension; fracture rate ratios between Extension years 4-7 (denosumab) and FREEDOM years 1-3 (placebo) reduced significantly for the wrist (0.57), forearm (0.57), humerus (0.42), and upper limb (0.52; p < 0.05 for all). Percentage increase in BMD from Extension baseline at the ultradistal radius, 1/3 radius, and total radius was significant by Extension year 7 (p < 0.05 for all).

CONCLUSIONS

Long-term treatment with denosumab decreases upper limb fracture risk and increases forearm BMD, suggesting beneficial effects on both cortical and trabecular bone accruing over time.

Relationship Between Bone Mineral Density T-Score and Nonvertebral Fracture Risk Over 10 Years of Denosumab Treatment

Although treat-to-target strategies are being discussed in osteoporosis, there is little evidence of what the target should be to reduce fracture risk maximally. We investigated the relationship between total hip BMD T-score and the incidence of nonvertebral fracture in women who received up to 10 years of continued denosumab therapy in the FREEDOM (3 years) study and its long-term Extension (up to 7 years) study. We report the percentages of women who achieved a range of T-scores at the total hip or femoral neck over 10 years of denosumab treatment (1343 women completed 10 years of treatment). The incidence of nonvertebral fractures was lower with higher total hip T-score. This relationship plateaued at a T-score between -2.0 and -1.5 and was independent of age and prevalent vertebral fractures, similar to observations in treatment-naïve subjects. Reaching a specific T-score during denosumab treatment was dependent on the baseline T-score, with higher T-scores at baseline more likely to result in higher T-scores at each time point during the study. Our findings highlight the importance of follow-up BMD measurements in patients receiving denosumab therapy because BMD remains a robust indicator of fracture risk. These data support the notion of a specific T-score threshold as a practical target for therapy in osteoporosis. © 2019 The Authors Journal of Bone and Mineral Research published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research (ASBMR).

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Atypical femur fractures: a survey of current practices in orthopedic surgery

The results of a self-administered online survey demonstrate that orthopedic surgeons' management practices for AFF are variable. These data will inform the development of clinical practice guidelines.

INTRODUCTION

We aimed to determine current AFF treatment practices of orthopedic surgeons to inform clinical practice guideline development.

METHODS

A self-administered online survey was developed and sequentially posted on the Orthopaedic Trauma Association (OTA) website from July to August 2015 and the Canadian Orthopaedic Association (COA) website from December 2015 to January 2016. Level of confidence in diagnosis and treatment as well as treatment preferences between respondents who self-identified as trauma surgeons vs. non-trauma surgeons were compared.

RESULTS

A total of 172 completed surveys were obtained (OTA, N = 100, 58%; COA, N = 72, 8%). Seventy-eight percent of respondents had treated ≥1 AFF in the previous 6 months. Seventy-six percent reported feeling extremely or very confident in diagnosing AFF (trauma 84% vs. non-trauma surgeons 70%, p = 0.04), and 63% reported feeling extremely or very confident in treating AFF (trauma 82%, non-trauma surgeons 50%, p < 0.01). Preferred management for complete and symptomatic incomplete AFFs was surgical fixation with a cephalomedullary nail (CMN) by 88 and 79%, respectively, while close follow-up was preferred for asymptomatic incomplete AFFs in 72% of respondents. Trauma surgeons used the CMN more frequently than non-trauma surgeons (90 vs. 76% p = 0.03). In patients with bilateral AFFs, with one side surgically treated, 56% were extremely likely to surgically treat the contralateral side, if symptomatic. Most felt guidelines (81%) and educational resources (73%) would be valuable.

CONCLUSIONS

Current orthopedic treatment practices for AFFs are variable. The results of this survey will inform the development of practice guidelines and educational resources.

Sex-specific association between obesity and self-reported falls and injuries among community-dwelling Canadians aged 65 years and older

This study investigated the relationship between body mass index (BMI) and falls among community-dwelling elderly. Results indicate that obesity is associated with increased falls and there appears to be a sex-specific difference with obese men at higher risk of falling. Obesity is identified as a risk factor for falls in men.

INTRODUCTION

The prevalence of falls, fall-related injuries, and obesity has increased over the last decade. The objectives of this study were to investigate sex-specific association and dose-response relationship between BMI and falls (and related injuries) among community-dwelling elderly.

METHODS

Our study sample consisted of 15,860 adults aged 65 years or older (6399 men and 9461 women) from the 2008-2009 Canadian Community Health Survey-Healthy Aging (CCHS-HA). Falls, fall-related injuries, and BMI measures were self-reported. For both sex, dose-response curves presenting the relationship between BMI, falls, and fall-related injuries were first examined. Thereafter, multivariate logistic regression analyses were also performed to investigate these relationships after adjustment for potentially confounding variables.

RESULTS

Of women, 21.7 % reported a fall and 16.9 % of men. The dose-response relationship between BMI and prevalence of falls showed that underweight and obese individuals reported falling more than normal and overweight individuals; this being more apparent in men than women. Finally, the dose relationship between BMI and prevalence of fall-related injuries showed that only obese men seem more likely to have sustained a fall-related injury. Results from the multivariate analysis showed that obesity in men was significantly associated with higher odds of falling odds ratio (OR) 1.33 (1.04-1.70) and was not significantly associated with higher odds of fall-related injuries OR 1.10 (0.66-1.84) over a 12-month period compared to normal weight men. For women, obesity was not significantly associated with higher fall prevalence OR 0.99 (0.79-1.25) and fall-related injuries OR 0.71 (0.51-1.00).

CONCLUSION

Obesity is associated with self-reported falls, and there appears to be a sex-specific difference in elderly persons.

Assaying Spontaneous Network Activity and Cellular Viability Using Multi-well Microelectrode Arrays

Microelectrode array (MEA) technology is a neurophysiological method that allows for the spontaneous measure of activity in neural cultures and determination of drug and chemical effects thereon. Recent introduction of multi-well MEA (mwMEA) formats have dramatically increased the throughput of this technology, allowing more efficient compound screening. Rapid characterization of compounds for neuroactivity or neurotoxicity hazard evaluation following acute, chronic, or developmental exposures ideally would also consider compound effects on cell health, and to do so in the same well requires a multiplexed approach. Procedures describing the multiplexed method to acute and developmental screening are described in this chapter.

The current economic burden of illness of osteoporosis in Canada

We estimate the current burden of illness of osteoporosis in Canada is double ($4.6 billion) our previous estimates ($2.3 billion) due to improved data capture of the multiple encounters and services that accompany a fracture: emergency room, admissions to acute and step-down non-acute institutions, rehabilitation, home-assisted or long-term residency support.

INTRODUCTION

We previously estimated the economic burden of illness of osteoporosis-attributable fractures in Canada for the year 2008 to be $2.3 billion in the base case and as much as $3.9 billion. The aim of this study is to update the estimate of the economic burden of illness for osteoporosis-attributable fractures for Canada based on newly available home care and long-term care (LTC) data.

METHODS

Multiple national databases were used for the fiscal-year ending March 31, 2011 (FY 2010/2011) for acute institutional care, emergency visits, day surgery, secondary admissions for rehabilitation, and complex continuing care, as well as national dispensing data for osteoporosis medications. Gaps in national data were supplemented by provincial and community survey data. Osteoporosis-attributable fractures for Canadians age 50+ were identified by ICD-10-CA codes. Costs were expressed in 2014 dollars.

RESULTS

In FY 2010/2011, the number of osteoporosis-attributable fractures was 131,443 resulting in 64,884 acute care admissions and 983,074 acute hospital days. Acute care costs were $1.5 billion, an 18 % increase since 2008. The cost of LTC was 33.4 times the previous estimate ($31 million versus $1.03 billion) because of improved data capture. The cost for rehabilitation and secondary admissions increased 3.4 fold, while drug costs decreased 19 %. The overall cost of osteoporosis was over $4.6 billion, an increase of 83 % from the 2008 estimate.

CONCLUSION

Since the 2008 estimate, new Canadian data on home care and LTC are available which provided a better estimate of the burden of osteoporosis in Canada. This suggests that our previous estimates were seriously underestimated.

Denosumab compared to other treatments to prevent or treat osteoporosis in individuals at risk of fracture: a systematic review and meta-analysis

The aim of this review is to compare the efficacy and safety of denosumab over other treatments for osteoporosis. The results of this study suggest that the safety of denosumab and its efficacy in reducing fractures is not significantly different from bisphosphonates. Denosumab was, however, more effective in increasing bone mineral density.

INTRODUCTION

This study was conducted to compare the efficacy and safety of denosumab over other pharmacological treatments for osteoporosis in individuals at risk of fracture.

METHODS

Randomised controlled trials comparing denosumab with another pharmacological treatment for osteoporosis were searched in MEDLINE, EMBASE and CENTRAL. Identified articles were screened by two independent reviewers and assessed for inclusion. Data from included studies were extracted and meta-analyses were conducted using random effects models.

RESULTS

Nine studies including a total of 4890 postmenopausal women were identified. The follow-up period varied from 12 to 24 months. In all studies except one, the comparator treatment was a bisphosphonate. There was no statistically significant difference between patients receiving denosumab and those receiving a bisphosphonate in terms of fracture risk (RR[95 % CI] = 1.15 [0.84-1.58]), adverse events (RR[95 % CI] = 0.99 [0.96-1.02]) or deaths (OR[95 % CI] = 0.58 [0.12-2.71]). Withdrawals due to adverse events were less frequent in denosumab than in other treatment groups but the difference did not reach statistical significance (OR[95 % CI] = 0.68 [0.45-1.04]). The percent change in bone mineral density at the total hip, lumbar spine, femoral neck and one-third radius was significantly higher in participants who received denosumab (e.g. mean difference [95 % CI] at the total hip: 1.06 [0.86-1.25]).

CONCLUSIONS

These results suggest that, after 12 to 24 months, the safety and efficacy of denosumab for reducing fracture risk is not significantly different from bisphosphonates despite higher gains in bone mineral density. In a clinical setting, denosumab may demonstrate greater effectiveness.

Editor's Highlight: Evaluation of a Microelectrode Array-Based Assay for Neural Network Ontogeny Using Training Set Chemicals

Thousands of compounds in the environment have not been characterized for developmental neurotoxicity (DNT) hazard. To address this issue, methods to screen compounds rapidly for DNT hazard evaluation are necessary and are being developed for key neurodevelopmental processes. In order to develop an assay for network formation, this study evaluated effects of a training set of chemicals on network ontogeny by measuring spontaneous electrical activity in neural networks grown on microelectrode arrays (MEAs). Rat (0-24 h old) primary cortical cells were plated in 48 well-MEA plates and exposed to 6 compounds: acetaminophen, bisindolylmaleimide-1 (Bis-1), domoic acid, mevastatin, sodium orthovanadate, and loperamide for a period of 12 days. Spontaneous network activity was recorded on days 2, 5, 7, 9, and 12 and viability was assessed using the Cell Titer Blue assay on day 12. Network activity (e.g. mean firing rate [MFR], burst rate [BR], etc), increased between days 5 and 12. Random Forest analysis indicated that across all compounds and times, temporal correlation of firing patterns (r), MFR, BR, number of active electrodes and % of spikes in a burst were the most influential parameters in separating control from treated wells. All compounds except acetaminophen (≤ 30 µM) caused concentration-related effects on one or more of these parameters. Domoic acid and sodium orthovanadate altered several of these parameters in the absence of cytotoxicity. Although cytotoxicity was observed with Bis1, mevastatin, and loperamide, some parameters were affected by these compounds at concentrations below those resulting in cytotoxicity. These results demonstrate that this assay may be suitable for screening of compounds for DNT hazard identification.

Denosumab or Zoledronic Acid in Postmenopausal Women With Osteoporosis Previously Treated With Oral Bisphosphonates

CONTEXT

Denosumab and zoledronic acid (ZOL) are parenteral treatments for patients with osteoporosis.

OBJECTIVE

The objective of the study was to compare the effect of transitioning from oral bisphosphonates to denosumab or ZOL on bone mineral density (BMD) and bone turnover.

DESIGN AND SETTING

This was an international, multicenter, randomized, double-blind trial.

PARTICIPANTS

A total of 643 postmenopausal women with osteoporosis previously treated with oral bisphosphonates participated in the study.

INTERVENTIONS

Subjects were randomized 1:1 to sc denosumab 60 mg every 6 months plus iv placebo once or ZOL 5 mg iv once plus sc placebo every 6 months for 12 months.

MAIN OUTCOME MEASURES

Changes in BMD and bone turnover markers were measured.

RESULTS

BMD change from baseline at month 12 was significantly greater with denosumab compared with ZOL at the lumbar spine (primary end point; 3.2% vs 1.1%; P < .0001), total hip (1.9% vs 0.6%; P < .0001), femoral neck (1.2% vs -0.1%; P < .0001), and one-third radius (0.6% vs 0.0%; P < .05). The median decrease from baseline was greater with denosumab than ZOL for serum C-telopeptide of type 1 collagen at all time points after day 10 and for serum procollagen type 1 N-terminal propeptide at month 1 and at all time points after month 3 (all P < .05). Median percentage changes from baseline in serum intact PTH were significantly greater at months 3 and 9 with denosumab compared with ZOL (all P < .05). Adverse events were similar between groups. Three events consistent with the definition of atypical femoral fracture were observed (two denosumab and one ZOL).

CONCLUSIONS

In postmenopausal women with osteoporosis previously treated with oral bisphosphonates, denosumab was associated with greater BMD increases at all measured skeletal sites and greater inhibition of bone remodeling compared with ZOL.

Efficacy of Lumiracoxib in Osteoarthritis: A Review of Nine Studies

Lumiracoxib is a cyclooxygenase-2 selective inhibitor in development for the treatment of osteoarthritis (OA), rheumatoid arthritis and acute pain. We reviewed nine clinical studies of 1 − 52 weeks' duration demonstrating the efficacy of lumiracoxib in OA. Male and female patients aged ≥ 18 years with primary OA of the hand, hip or knee received lumiracoxib, placebo or active comparators (diclofenac, celecoxib or rofecoxib). Lumiracoxib provided consistent reductions in OA pain intensity and improvements in the patient's global assessment of disease activity and functional status (assessed using the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire or the Australian/Canadian OA Hand Index). These results were superior to placebo and similar to the active comparators tested. In addition, lumiracoxib was consistently superior to placebo and generally similar to active comparators in terms of the new Outcome Measures in Clinical Trials and Osteoarthritis Research Society International criteria. These were used to provide a single measure of response to treatment, taking into account pain, the patient's global assessment of disease activity and functional status.

Characteristics of hyperparathyroid states in the Canadian multicentre osteoporosis study (CaMos) and relationship to skeletal markers

CONTEXT

PTH is an essential regulator of mineral metabolism; PTH hypersecretion may result in hyperparathyroidism including normocalcaemic, primary and secondary hyperparathyroidism.

OBJECTIVE

To examine the characteristics of participants with hyperparathyroid states and the relationship to bone mineral density (BMD).

DESIGN AND PARTICIPANTS

A cross-sectional study of 1872 community-dwelling men and women aged 35+ years (mostly Caucasian) with available serum PTH from Year 10 Canadian Multicentre Osteoporosis Study follow-up (2005-07). PTH was determined using a second-generation chemiluminescence immunoassay.

OUTCOME MEASURES

L1-L4, femoral neck and total hip BMD.

RESULTS

We established a PTH reference range (2·7-10·2 pmol/l) based on healthy participants (i.e. normal serum calcium, serum 25-hydroxyvitamin D, kidney function and body mass index, who were nonusers of antiresorptives, glucocorticoids and diuretics and not diagnosed with diabetes or thyroid disease). Participants with PTH levels in the upper reference range (5·6-10·2 pmol/l), representing a prevalence of 10·7%, had lower femoral neck and total hip BMD, by 0·030 g/cm(2) [95% confidence interval: 0·009; 0·051] and 0·025 g/cm(2) (0·001; 0·049), respectively, than those with levels 2·7-5·6 pmol/l. Participants with normocalcaemic and secondary hyperparathyroidism also had lower total hip BMD than those with levels 2·7-5·6 pmol/l, and CaMos prevalences of normocalcaemic, primary and secondary hyperparathyroidism were 3·3%, 1·4% and 5·2%, respectively.

CONCLUSION

We found reduced BMD in participants with accepted hyperparathyroid states but also a notable proportion of other participants that might benefit from having lower PTH levels.

Persistence at 12 months with denosumab in postmenopausal women with osteoporosis: interim results from a prospective observational study

To determine persistence with subcutaneous denosumab every 6 months in women being treated for osteoporosis, we conducted a single-arm prospective, observational study in the United States and Canada. Among 935 patients enrolled, 12-month persistence was 82%, with 66 patients (7%) reporting serious adverse events and 19 patients (2%) reporting fractures.

INTRODUCTION

Increased persistence with osteoporosis therapy is associated with reduced fracture risk. Denosumab reduced fracture risk in clinical trials; persistence in community settings is undetermined. This study evaluates persistence with denosumab in community practice in the United States (US) and Canada.

METHODS

In a 24-month multicenter, prospective, single-arm, observational study, women being treated for osteoporosis were enrolled ≤4 weeks after the first subcutaneous injection of denosumab. For this 12-month prespecified interim analysis, endpoints include persistence (one injection at study entry and another within 6 months + 8 weeks), attributes associated with persistence (univariate analysis), and serious adverse events (SAEs).

RESULTS

Among 935 patients (mean age 71 years), mean baseline T-scores were -2.18 (femoral neck) and -2.00 (lumbar spine); 50% of patients had experienced osteoporotic fracture(s). At 12 months, 82 % of patients were persistent with denosumab. Baseline factors significantly (p < 0.05) associated with higher persistence included use of osteoporosis medications >5 years previously, lumbar spine T-score > -2.5, and treatment by female physicians (US). Lower persistence was associated (p < 0.05) with psychiatric diagnoses including depression, southern US residence, being divorced, separated, or widowed (US), and prior hip fracture (Canada). SAEs were reported in 66 patients (7%); no SAEs of osteonecrosis of the jaw, atypical femoral fracture, fracture healing complications, hypocalcemia, eczema, or hypersensitivity were reported. Nineteen patients (2%) reported osteoporotic fractures.

CONCLUSIONS

The 12-month persistence observed in this single-arm open-label study of US and Canadian community practice extends the evidence regarding denosumab's potential role in reducing fracture risk in postmenopausal women with osteoporosis.

Denosumab significantly increases bone mineral density and reduces bone turnover compared with monthly oral ibandronate and risedronate in postmenopausal women who remained at higher risk for fracture despite previous suboptimal treatment with an oral bisphosphonate

Managing osteoporotic patients suboptimally adherent to bisphosphonates (BPs) is difficult. Such patients who remained at higher risk for fracture (≥1 risk factor) were transitioned to denosumab or a monthly oral BP. Denosumab-treated subjects had significantly greater increases in bone mineral density and decreases in bone turnover in this 12-month study.

INTRODUCTION

A clinical need exists to manage patients who are suboptimally adherent to oral BPs and remain at higher risk for fracture. Here, we compare the effects on bone mineral density (BMD) and bone turnover of transitioning such patients to denosumab or monthly oral BP (ibandronate or risedronate).

METHODS

In two previous multicenter, open-label studies, postmenopausal women ≥55 years previously treated with, though suboptimally adherent to, a daily or weekly BP were randomized to denosumab 60 mg subcutaneously every 6 months (N = 852) or oral BP 150 mg monthly (N = 851) for 12 months. In this combined post-hoc analysis, a subset of higher risk subjects was identified, and the percentage changes from baseline in BMD and serum C-telopeptide of type I collagen (sCTX-1) were assessed.

RESULTS

In the overall population, denosumab was associated with greater gains in BMD at 12 months than monthly oral BP at the total hip, femoral neck, and lumbar spine (p < 0.0001 for all). In higher risk subjects, denosumab led to greater gains in BMD than oral BPs at the total hip (2.2 vs 0.8 %), femoral neck (1.8 vs 0.3 %), and lumbar spine (3.7 vs 1.4 %) (p < 0.0001 for all). Denosumab also led to greater decreases in sCTX-1 in the overall population and higher risk subjects at months 1 and 6 (p < 0.0001 for both). Adverse events and serious adverse events were generally similar between treatment groups.

CONCLUSIONS

Transitioning to denosumab was well tolerated and more effective in increasing BMD and reducing bone turnover than cycling to a monthly oral BP treatment in subjects who remained at higher fracture risk despite suboptimal BP treatment.

The impact of educational interventions on modifiable risk factors for osteoporosis after a fragility fracture

The purpose of this study was to investigate the impact of two educational interventions on the intake of calcium and vitamin D supplements and modifiable risk factors for osteoporosis in women ≥50 years with a fragility fracture (FF). Within 6-8 months of fracture, women were randomized to one of three intervention groups: usual care (UC), written materials (WM), or videocassette and written materials (VC). The written materials for patients and their physician provided information on osteoporosis, FF, and available treatments; written materials for physician were provided through patients. The videocassette presented similar information as the written material, but in greater depth. Twelve months after randomization, the effectiveness of the interventions was assessed. The study cohort consisted of 1,175 women undiagnosed and untreated for osteoporosis. After 12 months, the mean intake of Ca supplements increased by 33, 93, and 91 mg/day for the UC, WM, and VC groups, respectively (p value, WM vs UC = 0.163; VC vs UC = 0.026); the corresponding mean increases for vitamin D were 58, 105, and 118 IU/day (p value, WM vs UC = 0.214; VC vs UC = 0.012). The proportion of women who increased their Ca and vitamin D intake by supplements was similar in all three groups. The intervention had a greater impact in those not taking supplements at randomization and had no impact on modifiable risk factors. In women without diagnosis and treatment for osteoporosis, the interventions seem effective at increasing the amounts of Ca and vitamin D supplements, but not effective at inciting more women to increase their consumption. Therefore, the clinical significance of the impact of the intervention is difficult to evaluate.

Denosumab compared with risedronate in postmenopausal women suboptimally adherent to alendronate therapy: efficacy and safety results from a randomized open-label study

Denosumab has been shown to reduce new vertebral, nonvertebral, and hip fractures in postmenopausal women with osteoporosis. In subjects who were treatment-naïve or previously treated with alendronate, denosumab was associated with greater gains in bone mineral density (BMD) and decreases in bone turnover markers when compared with alendronate-treated subjects. This trial was designed to compare the efficacy and safety of denosumab with risedronate over 12 months in postmenopausal women who transitioned from daily or weekly alendronate treatment and were considered to be suboptimally adherent to therapy. In this randomized, open-label study, postmenopausal women aged ≥55 years received denosumab 60 mg subcutaneously every 6 months or risedronate 150 mg orally every month for 12 months. Endpoints included percentage change from baseline in total hip BMD (primary endpoint), femoral neck, and lumbar spine BMD at month 12, and percentage change from baseline in sCTX-1 at months 1 and 6. Safety was also assessed. A total of 870 subjects were randomized (435, risedronate; 435, denosumab) who had a mean (SD) age of 67.7 (6.9) years, mean (SD) BMD T-scores of -1.6 (0.9), -1.9 (0.7), and -2.2 (1.2) at the total hip, femoral neck, and lumbar spine, respectively, and median sCTX-1 of 0.3 ng/mL at baseline. At month 12, denosumab significantly increased BMD compared with risedronate at the total hip (2.0% vs 0.5%), femoral neck (1.4% vs 0%), and lumbar spine (3.4% vs 1.1%; p<0.0001 at all sites). Denosumab significantly decreased sCTX-1 compared with risedronate at month 1 (median change from baseline of -78% vs -17%; p<0.0001) and month 6 (-61% vs -23%; p<0.0001). Overall and serious adverse events were similar between groups. In postmenopausal women who were suboptimally adherent to alendronate therapy, transitioning to denosumab was well tolerated and more effective than risedronate in increasing BMD and reducing bone turnover.

Pathological controversies in breast cancer: classification of ductal carcinoma in situ, sentinel lymph nodes and low volume metastatic disease and reporting of neoadjuvant chemotherapy specimens

The pathological classification of breast cancer is constantly being updated to reflect the advances in our clinical and biological understanding of the disease. This overview examines new insights into the classification and molecular biology of ductal carcinoma in situ, the pathological handling of sentinel lymph node biopsies and the identification of low volume disease (micrometastases and isolated tumour cells) and the handling and reporting of specimens after neoadjuvant therapy. The molecular subtypes of invasive breast cancer are also represented in ductal carcinoma in situ. It is hoped that alongside traditional histological features, such as cytological grade and the presence of necrosis, this will lead to better classification systems with improved prediction of clinical behaviour, in particular the risk of progression to invasive cancer, and enable more targeted management. Sentinel lymph node biopsy is now the standard of care for early stage breast cancer in clinically node-negative patients. However, the handling and reporting of these specimens remains controversial, largely related to the uncertainties regarding the clinical significance of micrometastases and isolated tumour cells. The increasing use of neoadjuvant therapies has introduced challenges for the pathologist in the handling and interpretation of these specimens. Grading the tumour response, particularly the identification of a complete pathological response, is prognostically important. However, there is still marked variability in reporting these specimens in routine practice, and consensus guidelines for the histopathology reporting of breast cancers after neoadjuvant chemotherapy based on robust, validated evidence are presently lacking.

The burden of illness of osteoporosis in Canada

To update the 1993 burden of illness of osteoporosis in Canada, administrative and community data were used to calculate the 2010 costs of osteoporosis at $2.3 billion in Canada or 1.3% of Canada's healthcare expenditures. Prevention of fractures in high-risk individuals is key to decrease the financial burden of osteoporosis.

INTRODUCTION

Since the 1996 publication of the burden of osteoporosis in 1993 in Canada, the population has aged and the management of osteoporosis has changed. The study purpose was to estimate the current burden of illness due to osteoporosis in Canadians aged 50 and over.

METHODS

Analyses were conducted using five national administrative databases from the Canadian Institute for Health Information for the fiscal-year ending March 31 2008 (FY 2007/2008). Gaps in national data were supplemented by provincial and community data extrapolated to national levels. Osteoporosis-related fractures were identified using a combination of most responsible diagnosis at discharge and intervention codes. Fractures associated with severe trauma codes were excluded. Costs, expressed in 2010 dollars, were calculated for osteoporosis-related hospitalizations, emergency care, same day surgeries, rehabilitation, continuing care, homecare, long-term care, prescription drugs, physician visits, and productivity losses. Sensitivity analyses were conducted to measure the impact on the results of key assumptions.

RESULTS

Osteoporosis-related fractures were responsible for 57,413 acute care admissions and 832,594 hospitalized days in FY 2007/2008. Acute care costs were estimated at $1.2 billion. When outpatient care, prescription drugs, and indirect costs were added, the overall yearly cost of osteoporosis was over $2.3 billion for the base case analysis and as much as $3.9 billion if a proportion of Canadians were assumed to be living in long-term care facilities due to osteoporosis.

CONCLUSIONS

Osteoporosis is a chronic disease that affects a large segment of the adult population and results in a substantial economic burden to the Canadian society.

Direct medical costs attributable to peripheral fractures in Canadian post-menopausal women

This study determined the cost of treating fractures at osteoporotic sites (except spine fractures) for the year following fracture. While the average cost of treating a hip fracture was the highest of all fractures ($46,664 CAD per fracture), treating other fractures also accounted for significant expenditures ($5,253 to $10,410 CAD per fracture).

INTRODUCTION

This study aims to determine the mean direct medical cost of treating fractures at peripheral osteoporotic sites in the year post-fracture (through 2 years post-hip fracture).

METHODS

Health administrative databases from the province of Quebec, Canada were used to estimate the cost of treating peripheral fractures at osteoporotic sites for the year following fracture (through 2 years for hip fractures). Included in costs analyses were physician claims, emergency and outpatient clinic costs, hospitalization costs, and subsequent costs for treatment of complications.

RESULTS

A total of 15,827 patients (mean age 72 years) who suffered one fracture at an osteoporotic site had data for analyses. Hip/femur fractures had the highest rate of hospital stays related to fracture (91%) and the highest rate of hospital stays associated with a post-fracture complication (8%). In the year following fracture, the mean (SD) costs (2009 Canadian dollars) of treating acute fractures and post-fracture complications were: hip/femur fracture $46,664 ($43,198), wrist fracture $5,253 ($18,982), and fractures at other peripheral sites $10,410 ($27,641). The average (SD) cost of treating post-fracture complications at the hip/femur in the second year post-fracture was $1,698 ($12,462). Hospitalizations associated with the fracture accounted for 88% of the total cost of fracture treatment.

CONCLUSIONS

The treatment of hip fractures accounts for a significant proportion of the costs associated with the treatment of peripheral osteoporotic fractures. Interventions to reduce the incidence of fractures, particularly hip fractures, would result in significant cost savings to the health care system and would preserve quality of life in many patients.

Algorithms can be used to identify fragility fracture cases in physician-claims databases

SUMMARY

Physician-billing claims databases can be used to determine the incidence of fractures in the community. This study tested three algorithms designed to accurately and reliably identify fractures from a physician-billing claims database and concluded that they were useful for identifying all types of fractures, except vertebral, sacral, and coccyx fractures.

INTRODUCTION

To develop and validate algorithms that identify fracture events from a physician-billing claims database (PCDs).

METHODS

Three algorithms were developed using physician's specialty, diagnostic, and medical service codes used in a PCD from the province of Quebec. Algorithm validity was assessed via calculation of positive predictive values (PPV; via verification of a sample of algorithm-identified cases with hospitalization files) and sensitivities (via cross-referencing respective algorithm-identified fracture cases with a well-characterized fracture cohort).

RESULTS

PPV and sensitivity varied across fracture sites. For most fracture sites, the PPV with algorithm 3 was higher than with algorithms 1 or 2. Except for knee fracture, the PPVs ranged from 0.81 to 0.96. Sensitivities were low at the vertebral, sacral, and coccyx sites (0.40-0.50), but high at all other fracture sites. For 95% of fractures, the fracture site identified by algorithm agreed with the fracture site from patients' medical records. Fracture dates identified by algorithm were within 2 days of the actual fracture date in 88% of fracture cases. Among cases identified by algorithm 3 to have had an open reduction (N = 461), 95% underwent surgery according to their respective medical charts.

CONCLUSION

Algorithms using PCDs are accurate and reliable for identifying incident fractures associated with osteoporosis-related fracture sites. The identification of these fractures in the community is important for helping to estimate the burden associated with osteoporosis and the utility of programs designed to reduce the rates of fragility fracture.

Infections in postmenopausal women with osteoporosis treated with denosumab or placebo: coincidence or causal association?

Serious adverse events of infections that occurred in subjects receiving denosumab or placebo in the Fracture Reduction Evaluation of Denosumab in Osteoporosis every 6 Months (FREEDOM) study were examined in detail. Serious adverse events of infections in denosumab subjects had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab.

INTRODUCTION

Denosumab reduces the risk for new vertebral, hip, and nonvertebral fractures compared with placebo. In the pivotal phase 3 fracture trial (FREEDOM), the overall safety profile and incidence of adverse events including adverse events of infections were similar between groups. Serious adverse events of erysipelas and cellulitis were more frequent in denosumab-treated subjects. In this report, we further evaluate the details of infectious events in FREEDOM to better understand if RANKL inhibition with denosumab influences infection risk.

METHODS

FREEDOM was an international multicenter, randomized, double-blind, placebo-controlled study in postmenopausal women with osteoporosis randomly assigned to receive placebo (n = 3,906) or denosumab 60 mg every 6 months (n = 3,902). The incidence of adverse events and serious adverse events categorized within the Medical Dictionary for Regulatory Activities system organ class, "Infections and Infestations," was compared between the placebo and denosumab groups by body systems and preferred terms. The temporal relationship between occurrence of serious adverse events of infections of interest and administration of denosumab was explored.

RESULTS

Serious adverse events of infections involving the gastrointestinal system, renal and urinary system, ear, and endocarditis were numerically higher in the denosumab group compared with placebo, but the number of events was small. No relationship was observed between serious adverse events of infections and timing of administration or duration of exposure to denosumab.

CONCLUSIONS

Serious adverse events of infections that occurred with denosumab treatment had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab.

Efficacy and safety of a novel delayed-release risedronate 35 mg once-a-week tablet

Dosing regimens of oral bisphosphonates are inconvenient and contribute to poor compliance. The bone mineral density response to a once weekly delayed-release formulation of risedronate given before or following breakfast was non-inferior to traditional immediate-release risedronate given daily before breakfast. Delayed-release risedronate is a convenient regimen for oral bisphosphonate therapy.

INTRODUCTION

We report the results of a randomized, controlled, clinical study assessing the efficacy and safety of a delayed-release (DR) 35 mg weekly oral formulation of risedronate that allows patients to take their weekly risedronate dose before or immediately after breakfast.

METHODS

Women with postmenopausal osteoporosis were randomly assigned to receive risedronate 5 mg immediate-release (IR) daily (n = 307) at least 30 min before breakfast, or risedronate 35 mg DR weekly, either at least 30 min before breakfast (BB, n = 308) or immediately following breakfast (FB, n = 307). Bone mineral density (BMD), bone turnover markers (BTMs), fractures, and adverse events were evaluated. The primary efficacy variable was percent change from baseline in lumbar spine BMD at Endpoint.

RESULTS

Two hundred fifty-seven subjects (83.7%) in the IR daily group, 252 subjects (82.1%) in the DR FB weekly group, and 258 subjects (83.8%) in the DR BB weekly group completed 1 year. Both DR weekly groups were determined to be non-inferior to the IR daily regimen. Mean percent changes in hip BMD were similar across groups. The magnitude of BTM response was similar across groups; some statistical differences were seen that were small and deemed by investigators to have no major clinical importance. The incidence of adverse events leading to withdrawal and serious adverse events were similar across treatment groups. All three regimens were well tolerated.

CONCLUSIONS

Risedronate 35 mg DR weekly is similar in efficacy and safety to risedronate 5 mg IR daily, and will allow patients to take their weekly risedronate dose immediately after breakfast.

The impact of two educational interventions on osteoporosis diagnosis and treatment after fragility fracture: a population-based randomized controlled trial

This study assessed whether osteoporosis diagnosis and treatment after an osteoporotic fracture can be increased by providing osteoporosis reading material to patients and family doctors or by watching a videocassette about osteoporosis. Educating patients about osteoporosis had little impact on whether a woman received an osteoporosis diagnosis or treatment.

INTRODUCTION

The purpose of this study was to investigate the impact of two education-based interventions on osteoporosis diagnosis and treatment in women ≥ 50 years of age after fragility fracture.

METHODS

Six to eight months after fracture, women were randomized into three groups: (1) control, (2) written materials, or (3) videocassette and written materials. Written materials for both the patient and physician detailed osteoporosis, fragility fracture, and available treatments; written materials for physicians were provided through patients. The educational videocassette presented similar information as the written material, but in greater depth. Rates of osteoporosis diagnosis and treatment following intervention were compared among groups using survival analysis methods. Statistical significance was set at p < 0.0167.

RESULTS

At randomization, 1,174 women were without osteoporosis diagnosis and treatment, and after follow-up, 12% of the control group, 15% of the written materials group (p = 0.073), and 16% (p = 0.036) of the videocassette and written materials group were diagnosed with osteoporosis (statistical comparisons to control). Treatment rates were 8% for the control group, 12% for the written materials group (p = 0.052), and 11% for the videocassette and written materials group (p = 0.157). At randomization, 1,314 women were without treatment and after follow-up therapy was initiated in 10% of the control group, 13% of the written materials group (p = 0.107), and 13% of the videocassette and written materials group (p = 0.238).

CONCLUSIONS

The educational interventions assessed in this trial were not satisfactory to increase osteoporosis diagnosis or treatment in recently fractured women to a clinically meaningful degree.

Fracture prediction and calibration of a Canadian FRAX® tool: a population-based report from CaMos

A new Canadian WHO fracture risk assessment (FRAX®) tool to predict 10-year fracture probability was compared with observed 10-year fracture outcomes in a large Canadian population-based study (CaMos). The Canadian FRAX tool showed good calibration and discrimination for both hip and major osteoporotic fractures.

INTRODUCTION

The purpose of this study was to validate a new Canadian WHO fracture risk assessment (FRAX®) tool in a prospective, population-based cohort, the Canadian Multicentre Osteoporosis Study (CaMos).

METHODS

A FRAX tool calibrated to the Canadian population was developed by the WHO Collaborating Centre for Metabolic Bone Diseases using national hip fracture and mortality data. Ten-year FRAX probabilities with and without bone mineral density (BMD) were derived for CaMos women (N = 4,778) and men (N = 1,919) and compared with observed fracture outcomes to 10 years (Kaplan-Meier method). Cox proportional hazard models were used to investigate the contribution of individual FRAX variables.

RESULTS

Mean overall 10-year FRAX probability with BMD for major osteoporotic fractures was not significantly different from the observed value in men [predicted 5.4% vs. observed 6.4% (95%CI 5.2-7.5%)] and only slightly lower in women [predicted 10.8% vs. observed 12.0% (95%CI 11.0-12.9%)]. FRAX was well calibrated for hip fracture assessment in women [predicted 2.7% vs. observed 2.7% (95%CI 2.2-3.2%)] but underestimated risk in men [predicted 1.3% vs. observed 2.4% (95%CI 1.7-3.1%)]. FRAX with BMD showed better fracture discrimination than FRAX without BMD or BMD alone. Age, body mass index, prior fragility fracture and femoral neck BMD were significant independent predictors of major osteoporotic fractures; sex, age, prior fragility fracture and femoral neck BMD were significant independent predictors of hip fractures.

CONCLUSION

The Canadian FRAX tool provides predictions consistent with observed fracture rates in Canadian women and men, thereby providing a valuable tool for Canadian clinicians assessing patients at risk of fracture.

Fragility fractures and the osteoporosis care gap in women: the Canadian Multicentre Osteoporosis Study

Canadian women over 50 years old were studied over a 10-year period to see if those who sustained a fracture (caused by minimal trauma) were receiving the recommended osteoporosis therapy. We found that approximately half of these women were not being treated, indicating a significant care gap in osteoporosis treatment.

INTRODUCTION

Prevalent fragility fracture strongly predicts future fracture. Previous studies have indicated that women with fragility fractures are not receiving the indicated treatment. We aimed to describe post fracture care in Canadian women using a large, population-based prospective cohort that began in 1995-1997.

METHODS

We followed 5,566 women over 50 years of age from across Canada over a period of 10 years in the Canadian Multicentre Osteoporosis Study. Information on medication use and incident clinical fragility fractures was obtained during a yearly questionnaire or interview and fractures were confirmed by radiographic/medical reports.

RESULTS

Over the 10-year study period, 42-56% of women with yearly incident clinical fragility fractures were not treated with an osteoporosis medication. During year 1 of the study, 22% of the women who had experienced a fragility fracture were on treatment with a bisphosphonate and 26% were on hormone therapy (HT). We were not able to differentiate HT use for menopause symptoms vs osteoporosis. Use of bisphosphonate therapy increased over time; odds ratio (OR) for use at year 10 compared to use at year 1 was 3.65 (95% confidence interval (CI) 1.83-7.26). In contrast, HT use declined, with an OR of 0.07 (95%CI 0.02-0.24) at year 10 compared to year 1 of the study.

CONCLUSION

In a large population-based cohort study, we found a therapeutic care gap in women with osteoporosis and fragility fractures. Although bisphosphonate therapy usage improved over time, a substantial gap remains.

Safety and tolerability of bazedoxifene in postmenopausal women with osteoporosis: results of a 5-year, randomized, placebo-controlled phase 3 trial

Findings from this 5-year phase 3 study of postmenopausal women with osteoporosis showed that bazedoxifene was associated with an overall favorable safety and tolerability profile, with no evidence of endometrial or breast stimulation. Overall, the results at 5 years were consistent with those seen at 3 years.

INTRODUCTION

We report safety and tolerability findings from a 5-year randomized, double-blind, phase 3 study of bazedoxifene in postmenopausal women with osteoporosis.

METHODS

In the core study, healthy postmenopausal women with osteoporosis (N=7,492; mean age, 66.4 years) were randomized to daily doses of bazedoxifene 20 or 40 mg, raloxifene 60 mg, or placebo for 3 years. During the 2-year study extension, the raloxifene 60-mg treatment arm was discontinued after the 3-year database was finalized, and subjects receiving bazedoxifene 40 mg were transitioned in a blinded manner to bazedoxifene 20 mg (bazedoxifene 40-/20-mg group) after 4 years. Safety and tolerability data are reported for subjects in the bazedoxifene 20- and 40-/20-mg and placebo groups; efficacy findings are reported elsewhere.

RESULTS

A total of 3,146 subjects in the bazedoxifene 20- and 40-mg and placebo groups were enrolled in the extension study (years 4 and 5). Overall, the 5-year incidence of adverse events (AEs), serious AEs, and discontinuations due to AEs were similar among groups. The incidence of hot flushes and leg cramps was higher with bazedoxifene compared with placebo. Venous thromboembolic events, primarily deep vein thrombosis, were more frequently reported in the bazedoxifene groups compared with the placebo group. Reports of cardiac disorders and cerebrovascular events were few and evenly distributed among groups. Bazedoxifene showed a neutral effect on the breast and endometrium.

CONCLUSION

Bazedoxifene was associated with an overall favorable safety and tolerability profile in postmenopausal women with osteoporosis over 5 years of therapy, consistent with findings at 3 years.

Denosumab improves density and strength parameters as measured by QCT of the radius in postmenopausal women with low bone mineral density

BACKGROUND

Bone strength is determined by both cortical and trabecular bone compartments and can be evaluated radiologically through measurement of bone density and geometry. Quantitative computed tomography (QCT) separately assesses cortical and trabecular bone reliably at various sites, including the distal radius where there is a gradation of cortical and trabecular bone. We evaluated the effect of denosumab, a fully human monoclonal antibody that inhibits RANK ligand, on distal radius QCT in women with low bone mass to assess the impact of this novel therapy separately on trabecular and cortical bone.

METHODS

Postmenopausal women (n=332) with spine areal bone mineral density (BMD) T-scores between -1.0 and -2.5 received denosumab 60 mg or placebo every 6 months during the 24-month study. QCT measurements along the distal radius were made using a whole-body computed tomography scanner and were used to determine the percentage change from baseline in volumetric BMD; volumetric bone mineral content (BMC); cortical thickness; volume; circumference; and density-weighted polar moment of inertia (PMI), a derived index of bone strength.

RESULTS

Denosumab treatment significantly increased total BMD and BMC along the radius (proximal, distal, and ultradistal sections). At 24 months, the ultradistal region had the greatest percentage increase in total BMD (4.7% [95% CI, 3.6-5.7]; P<0.001) and total BMC (5.7% [95% CI, 4.8-6.6]; P<0.001) over placebo. When cortical and trabecular bone at the proximal and distal regions were separately assessed, cortical bone had significant (P<0.001) increases in BMD, BMC, and thickness, and trabecular bone had a significant increase in BMD relative to placebo (P<0.05). Bone strength, estimated by density-weighted PMI, significantly increased compared with placebo after 6 months of treatment, with the largest percentage increase occurring at 24 months in the ultradistal region (6.6% [95% CI, 5.6-7.6]; P<0.0001).

CONCLUSIONS

QCT measurements demonstrated that denosumab significantly increased BMD, BMC, and PMI along the radius over 24 months. Additionally, denosumab prevented the decrease in QCT-measured cortical thickness observed in the placebo group. These data extend the evidence from previous dual-energy X-ray absorptiometry studies for a positive effect of denosumab on both the cortical and trabecular bone compartments and propose a possible mechanism for the reduction in fracture risk achieved with denosumab therapy.

Factors influencing the treatment of osteoporosis following fragility fracture

Treatment rates of osteoporosis after fracture are very low. Women who suffer a fragility fracture have a greater chance of receiving anti-fracture treatment if they had low bone mineral density (BMD), a fracture at the hip, femur or pelvis, administration of calcium and vitamin D supplements and/or an age > or =60 years.

INTRODUCTION

This investigation identifies the predictors of osteoporosis treatment 6 to 8 months following fragility fracture in women >50 years of age.

METHODS

In this prospective cohort study, women were recruited 0 to 16 weeks following fracture and classified as having experienced fragility or traumatic fractures (phase 1). Six to 8 months following fracture, women completed a questionnaire on demographic features, clinical characteristics and risk factors for osteoporosis (phase 2). Osteoporosis treatment was defined as initiating anti-fracture therapy (bisphosphonate, raloxifene, nasal calcitonin and teriparatide) after fracture in those previously untreated.

RESULTS

Of the 1,273 women completing phase 1, 1,001 (79%) sustained a fragility fracture, and of these women, 738 were untreated for osteoporosis at phase 1 and completed the phase 2 questionnaire. Significant predictors of treatment included BMD result, fracture site, administration of calcium and vitamin D supplements at the time of fracture and age > or =60 years. All other risk factors for osteoporosis, such as fracture history after the age of 40 years, family history of osteoporosis and comorbidities did not significantly influence the treatment rate.

CONCLUSIONS

Physicians largely based their decision to treat on BMD results and not on the clinical event-fragility fracture.

The impact of incident fractures on health-related quality of life: 5 years of data from the Canadian Multicentre Osteoporosis Study

Using prospective data from the Canadian Multicentre Osteoporosis Study (CaMos), we compared health utilities index (HUI) scores after 5 years of follow-up among participants (50 years and older) with and without incident clinical fractures. Incident fractures had a negative impact on HUI scores over time.

INTRODUCTION

This study examined change in health-related quality of life (HRQL) in those with and without incident clinical fractures as measured by the HUI.

METHODS

The study cohort was 4,820 women and 1,783 men (50 years and older) from the CaMos. The HUI was administered at baseline and year 5. Participants were sub-divided into incident fracture groups (hip, rib, spine, forearm, pelvis, other) and were compared with those without these fractures. The effects of both time and fracture type on HUI scores were examined in multivariable regression analyses.

RESULTS

Men and women with hip fractures, compared to those without, had lower HUI measures that ranged from -0.05 to -0.25. Both women and men with spine fractures had significant deficits on the pain attributes (-0.07 to -0.12). In women, self-care (-0.06), mobility and ambulation (-0.05) were also negatively impacted. Women with rib fractures had deficits similar to women with spine fractures, and these effects persisted over time. In men, rib fractures did not significantly affect HUI scores. Pelvic and forearm fractures did not substantially influence HUI scores.

CONCLUSION

The HUI was a sensitive measure of HRQL change over time. These results will inform economic analyses evaluating osteoporosis therapies.

Risk factors for low BMD in healthy men age 50 years or older: a systematic review

SUMMARY

In this systematic review, we summarize risk factors for low bone mineral density and bone loss in healthy men age 50 years or older. Consistent risk factors were: age, smoking, low weight, physical/functional limitations, and previous fracture. Data specific to men has clinical and policy implications.

INTRODUCTION

Osteoporosis is a significant health care problem in men as well as women, yet the majority of evidence on diagnosis and management of osteoporosis is focused on postmenopausal women. The objective of this systematic review is to examine risk factors for low bone mineral density (BMD) and bone loss in healthy men age 50 years or older.

MATERIALS AND METHODS

A systematic search for observational studies was conducted in MEDLINE, Cochrane Database of Systematic Reviews, DARE, CENTRAL, CINAHL and Embase, Health STAR. The three main search concepts were bone density, densitometry, and risk factors. Trained reviewers assessed articles using a priori criteria.

RESULTS

Of 642 screened abstracts, 299 articles required a full review, and 25 remained in the final assessment. Consistent risk factors for low BMD/bone loss were: advancing age, smoking, and low weight/weight loss. Although less evidence was available, physical/functional limitations and prevalent fracture (after age 50) were also associated with low BMD/bone loss. The evidence was inconsistent or weak for physical activity, alcohol consumption, calcium intake, muscle strength, family history of fracture/osteoporosis, and height/height loss.

CONCLUSION

In this systematic review, we identified several risk factors for low BMD/bone loss in men that are measurable in primary practice.

The osteoporosis care gap in men with fragility fractures: the Canadian Multicentre Osteoporosis Study

We examined osteoporosis diagnosis/treatment in 2,187 community dwelling men age 50+. After five years in the study, 90% of men with fragility fractures remained undiagnosed and untreated for osteoporosis. The need to treat fragility fractures is well established in guidelines, and these numbers represent an important care gap.

INTRODUCTION

Whether physicians in the community are recognizing and appropriately treating osteoporosis and fragility fractures in men remains unknown. We examined the rate of diagnosis and treatment in community dwelling men participating in the Canadian Multicentre Osteoporosis Study (CaMos).

METHODS

Between February 1996 and September 2002, 2,187 participants were recruited from nine sites across Canada and prospectively followed. Information on osteoporosis diagnosis, fractures, medications were collected annually by a detailed questionnaire. DXA examination of lumbar spine (L1-4) and hip were conducted at baseline and year five.

RESULTS

Diagnosis and treatment in men with clinical fragility fractures was low: at baseline and year five only 2.3% and 10.3% of men with a clinical fracture reported an osteoporosis diagnosis, respectively. At year five, 90% of men with a clinical fragility fracture were untreated. Hip fractures were the most commonly treated (37.5% by year five). A diagnosis of osteoporosis resulted in greater treatment: 67% of participants with diagnosed osteoporosis were treated with a bisphosphonate and 87% were taking calcium and/or vitamin D (year five).

CONCLUSIONS

In this population-based study, both a diagnostic and therapeutic gap existed between knowledge and practice related to fragility fractures and osteoporosis in men aged >or=50 years.

Effect of raloxifene after recombinant teriparatide [hPTH(1-34)] treatment in postmenopausal women with osteoporosis

Loss of bone mineral density occurs after discontinuation of teriparatide, if no subsequent treatment is given. Sequential raloxifene prevented rapid bone loss at lumbar spine and further increased bone mineral density (BMD) at femoral neck, whether raloxifene was started immediately or after a one-year delay following teriparatide treatment.

INTRODUCTION

We compared the sequential effects of raloxifene treatment with a placebo on teriparatide-induced increases in bone mineral density (BMD). A year of open-label raloxifene extended the study to assess the response with and without delay after discontinuation of teriparatide.

METHODS

Following a year of open-label teriparatide 20 mug/day treatment, postmenopausal women with osteoporosis were randomly assigned to raloxifene 60 mg/day (n = 157) or a placebo (n = 172) for year 2, followed by a year of open-label raloxifene. BMD was measured by dual energy x-ray absorptiometry.

RESULTS

The raloxifene and placebo groups showed a decrease in lumbar spine (LS) BMD in year 2 for raloxifene and placebo groups (-1.0 +/- 0.3%, P = 0.004; and -4.0 +/- 0.3%, P < 0.001, respectively); the decrease was less with raloxifene (P < 0.001). Open-label raloxifene treatment reversed the LS BMD decrease with a placebo, resulting in similar decreases 2 years after randomization (-2.6 +/- 0.4% (raloxifene-raloxifene) and -2.7 +/- 0.4% (placebo-placebo). At study end, LS and femoral neck (FN) BMD were higher than pre-teriparatide levels, with no significant differences between the raloxifene-raloxifene and placebo-raloxifene groups, respectively (LS: 6.1 +/- 0.5% vs. 5.1 +/- 0.5%; FN: 3.4 +/- 0.6% vs. 3.0 +/- 0.5%).

CONCLUSION

Sequential raloxifene prevented rapid bone loss at the LS and increased FN BMD whether raloxifene was started immediately or after a one-year delay following teriparatide treatment.

The care gap in diagnosis and treatment of women with a fragility fracture

In women aged 50 years or more who experienced a fracture, 81% suffered a fragility fracture. Six to eight months after fragility fracture, 79% had either not been investigated for osteoporosis or prescribed anti-fracture therapy. Despite fragility fractures being common in this population osteoporosis is under-diagnosed and under-treated.

INTRODUCTION

The objective of this study was to evaluate the diagnostic and treatment rates for osteoporosis six months following fragility fracture.

METHODS

This prospective cohort study was set in the general community from the Province of Quebec, Canada. Women at least 50 years of age who suffered a fracture were recruited during their initial visit to the hospital and had their fracture type classified as either fragility or traumatic. Six-to-eight months after fragility fracture, women were again contacted to evaluate the diagnostic and treatment rates of osteoporosis.

RESULTS

Of the 2,075 women recruited over a 25 month period 1,688 (81%) sustained a fragility fracture and 387 (19%) sustained a traumatic fracture. Nine hundred and three participants with a fragility fracture were again contacted six-to-eight months after fracture. For the 739 women not on treatment on the recruitment day, only 15.4% initiated pharmacological therapy in the six-to-eight-month period following fracture and 79.0% had either not been investigated for osteoporosis or prescribed anti-fracture treatment.

CONCLUSIONS

The proportion of fragility fractures to total fractures is higher than previously reported. Despite the availability of diagnostic modalities, effective treatments, and adequate health care assessments, there is a substantial care gap in the management of osteoporosis.

Zoledronic acid efficacy and safety over five years in postmenopausal osteoporosis

In a 5-year study involving 119 postmenopausal women, zoledronic acid 4 mg given once-yearly for 2, 3 or 5 years was well tolerated with no evidence of excessive bone turnover reduction or any safety signals. BMD increased significantly. Bone turnover markers decreased from baseline and were maintained within premenopausal reference ranges.

INTRODUCTION

After completion of the core study, two consecutive, 2-year, open-label extensions investigated the efficacy and safety of zoledronic acid 4 mg over 5 years in postmenopausal osteoporosis.

METHODS

In the core study, patients received 1 to 4 mg zoledronic acid or placebo. In the first extension, most patients received 4 mg per year and then patients entered the second extension and received 4 mg per year or calcium only. Patients were divided into three subgroups according to years of active treatment received (2, 3 or 5 years). Changes in BMD and bone turnover markers (bone ALP and CTX-I) were assessed.

RESULTS

All subgroups showed substantial increases in BMD and decreases in bone markers. By the end of the core study, 37.5% of patients revealed a suboptimal reduction (< 30%) of bone ALP levels. After subsequent study drug administration during the extensions, there was no evidence of progressive reduction of bone turnover markers. Furthermore, increased marker levels after treatment discontinuation demonstrates preservation of bone remodelling capacity.

CONCLUSIONS

This study showed that zoledronic acid 4 mg once-yearly was well tolerated and effective in reducing biomarkers over 5 years. Detailed analysis of bone marker changes, however, suggests that this drug regimen causes insufficient reduction of remodelling activity in one third of patients.