A new digital case-based educational program Orthogeriatrics TeleECHO, a strategy to improve the care of fragility fracture patients

Participation in Orthogeriatrics TeleECHO was associated with improvement in physicians' knowledge and self-confidence in managing elderly patients with fractures.

PURPOSE

To develop and conduct an interactive case-based virtual TeleECHO program to expand the knowledge of healthcare professionals in the field of orthogeriatrics.

METHODS

The project included twelve 90-min sessions for physicians and healthcare managers. Each session was based on real clinical cases discussed by the multidisciplinary group of faculty. The efficacy of the project was assessed using questionnaires.

RESULTS

The attendance of individual sessions ranged from 129 to 224 with the total number of participants 829; 25% of participants were from remote rural regions. A survey conducted at the beginning of the project showed insufficient knowledge and ability to apply the concepts of orthogeriatrics. A final questionnaire showed that 74% of respondents participated in most sessions, with 94% wishing to continue participating in further sessions. There was a statistically significant overall improvement in confidence of caring for fragility fracture patients with an effect size of 0.75 (p<0.001). The proportion of responders who were able to apply their new knowledge in clinical practice shortly after TeleECHO showed a substantial increase (p<0.0001).

CONCLUSION

The Orthogeriatrics TeleECHO program was effective in changing perceptions and self-confidence of the participants, and applying knowledge acquired to patient care. This model of learning could be applied in other countries in other languages to improve post-fracture care worldwide.

An experience- and preference-based EQ-5D-3L value set derived using 18 months of longitudinal data in patients who sustained a fracture: results from the ICUROS

INTRODUCTION

EQ-5D-3L preference-based value sets are predominately based on hypothetical health states and derived in cross-sectional settings. Therefore, we derived an experience-based value set from a prospective observational study.

METHODS

The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) was a multinational study on fragility fractures, prospectively collecting EQ-5D-3L and Time trade-off (TTO) within two weeks after fracture (including pre-fracture recall), and at 4, 12, and 18 months thereafter. We derived an EQ-5D-3L value set by regressing the TTO values on the ten impairment levels in the EQ-5D-3L. We explored the potential for response shift and whether preferences for domains vary systematically with prior impairment in that domain. Finally, we compared the value set to 25 other EQ-5D-3L preference-based value sets.

RESULTS

TTO data were available for 12,954 EQ-5D-3L health states in 4683 patients. All coefficients in the value set had the expected sign, were statistically significant, and increased monotonically with severity of impairment. We found evidence for response shift in mobility, self-care, and usual activities. The value set had good agreement with the only other experience- and preference-based value set, but poor agreement with all hypothetical value sets.

CONCLUSIONS

We present an experience- and preference-based value set with high face validity. The study indicates that response shift may be important to account for when deriving value sets. Furthermore, the study suggests that perspective (experienced versus hypothetical) is more important than country setting or demographics for valuation of EQ-5D-3L health states.

A summary of the Russian clinical guidelines on the diagnosis and treatment of osteoporosis

Key statements of the Russian clinical guidelines on the diagnosis and treatment of osteoporosis are summarized. They were developed by a task force representing the key Russian professional associations involved in the management of osteoporosis and approved by the Russian Ministry of Health.

PURPOSE

To summarize key statements of the Russian clinical practice guidelines for the diagnosis and treatment of osteoporosis.

METHODS

The Russian clinical guidelines on the diagnosis and treatment of osteoporosis were developed by a task force representing the key Russian professional associations involved in the management of osteoporosis: These comprised the Russian Association of Endocrinologists, the Russian Association for Osteoporosis, the Association of Rheumatologists of Russia, the Association of Orthopedic surgeons and Traumatologists of Russia, the Russian Association of Gynecologists-Endocrinologists, and the Russian Association of Gerontologists and Geriatrics. The guidelines are based on a systematic literature review and principles of evidence-based medicine and were compiled in accordance with the requirements for clinical recommendations developed by the Ministry of Health of the Russian Federation.

RESULTS

Key statements included in the Russian guidelines of osteoporosis approved by the Russian Ministry of Health in 2021 are summarized. The statements are graded based on levels of evidence and supported by short comments. The guidelines are focused on the current approach to screening, diagnosis, differential diagnosis, and treatment of osteoporosis.

CONCLUSION

These guidelines are a practical tool for general practitioners, as well as medical specialists, primarily endocrinologists, rheumatologists, orthopedic surgeons, and other physicians who are involved in the management of patients with osteoporosis.

AB0447 IRREVERSIBLE ORGAN DAMAGE IN PERI- AND POSTMENOPAUSAL WOMEN WITH SYSTEMIC LUPUS ERYTHEMATOSUS IN REMISSION

Background:

Although the survival of patients with systemic lupus erythematosus (SLE) has improved, irreversible organ damage remains a critical concern. Long-standing inflammation, drug-related side effects and comorbidities may eventually cause permanent organ damage even in remission[1].

Objectives:

To describe irreversible organ damage in peri- and postmenopausal women with SLE in remission and low disease activity, to find predictors of damage progression.

Methods:

234 peri- and postmenopausal women with SLE were included (mean age 49,94±9,1 years) in our study. All women were under outpatient observation in St.Petersburg State Clinical Rheumatology Hospital #25 (Russia). Mean disease duration was 8,9±7,5 years. We analyzed treatment regimens and doses of glucocorticoids (GC) based on source medical documents. To assess disease activity, we used SLEDAI-2K and LLDAS. To assess organ damage, we used SLICC damage index (SDI).

Results:

94,3% of women have been taking GC during our study. Median of maintenance dose was 12,5 mg per day. Almost a half of all women (44,8%, n=105) in our study were postmenopausal (mean duration of menopause was 11,1±7,1 years). A half of all patients had low disease activity (44,4%, n=111) or were in remission (18,8%, n=44) according to SLEDAI-2K. 26,5% (n=65) of patients had all 5 criteria and 45,1 % (n=115) of patients had 4 of 5 criteria according to LLDAS. Critical organ damage (SDI>4) was observed in 68,8% (n=161) of women with SLE. Moderate (1≤SDI≤4) and low (SDI=1) damage had 25,6% (n=60) and 6,4% (n=15) of patients respectively. Musculoskeletal damage was on the first place among others: 37,6% (n=88) of patients had osteoporosis with fractures and 34,2% (n=80) had muscle weakness. In 75 women with SLE of osteoporotic fractures occurred in remission or low disease activity (LLDAS). Progression of irreversible organ damage in remission or low disease activity (LLDAS) had 62% (n=145) of women with SLE. Multifactorial logistic regression analysis of factors associated with organ damage in SLE showed that only patients age (р=0.013215), cumulative dose of GC (р=0.000047) and therapy with cyclophosphamide (р=0.041505) were statistically significant.

Conclusion:

Progression of irreversible organ damage in peri- and postmenopausal women with SLE may occur despite remission or low disease activity. There are no doubts that organ damage accrual is associated with CG therapy. Correction of GC dose or discontinuation of GC treatment in remission can predict organ damage accrual in SLE including osteoporosis and osteoporotic fractures.

References:

[1]Frodlund M, Reid S, Wetterö J, Dahlström Ö, Sjöwall C, Leonard D. The majority of Swedish systemic lupus erythematosus patients are still affected by irreversible organ impairment: factors related to damage accrual in two regional cohorts. Lupus. 2019;28(10):1261–1272. doi:10.1177/0961203319860198

Disclosure of Interests:

None declared

Multicenter Epidemiological Study of Osteoporotic Fractures in Eurasia (EVA Study). A step towards reducing the burden of age-related diseases

To extend elderly patients’ active longevity, practitioners all over the world need a precise clinical instrument to assess the 10-year osteoporotic fractures probability and choose the optimal preventive intervention. The purpose of this research is to assess major osteoporotic (OP) fractures incidence in CIS countries and to create country-specific computing FRAX clinical prediction tools. Method. We carried out a cohort population-based study (EVA) in Russia, Belarus, Armenia, Moldova, Kazakhstan, and Uzbekistan in 2011-2018. The age- and sexspecific OP fracture incidence values were incorporated into the computing FRAX models. Results. We revealed that the highest standardized HP incidence was obtained in Kazakhstan (338 and 255 per 100 000 per year for women and men older than 50 years resp.) and Moldova (331, 0 and 155, 0 per year for women and men resp.), the lowest in Armenia (201 and 136 per 100 000 per year for women and men resp.). The FRAX models showed that in Kazakhstan, Uzbekistan, and Moldova, elderly people had the highest hip fracture probabilities. Estimates reveal that the OP fractures numbers in the EVA-project countries will grow by 1.5-3 times by 2050. Conclusion. The created national FRAX instruments should enhance the accuracy of determining fracture probability among older people, help clinicians to make decisions concerning OP prophylactic, and to step forward to reducing the burden of age-related diseases.

A surrogate FRAX model for the Kyrgyz Republic

The hip fracture rates from Kazakhstan were used to create a surrogate FRAX® model for the Kyrgyz Republic.

INTRODUCTION

The International Society for Clinical Densitometry and International Osteoporosis Foundation recommend utilizing a surrogate FRAX model, based on the country-specific risk of death, and fracture data based on a country where fracture rates are considered to be representative of the index country.

OBJECTIVE

This paper describes a surrogate FRAX model for the Kyrgyz Republic.

METHODS

The FRAX model used the incidence of hip fracture from the neighbouring country of Kazakhstan and the death risk for the Kyrgyz Republic.

RESULTS

Compared with the model for Kazakhstan, the surrogate model gave somewhat higher 10-year fracture probabilities for men between 60 and 80 years of age and lower probabilities for men above the age of 80. For women the probabilities were similar up to the age of 75-80 years and then lower. There were very close correlations in fracture probabilities between the surrogate and authentic models (1.00) so that the use of the Kyrgyz model had little impact on the rank order of risk. It was estimated that 2752 hip fractures arose in 2015 in individuals over the age of 50 years in the Kyrgyz Republic, with a predicted increase by 207% to 8435 in 2050.

CONCLUSION

The surrogate FRAX model for the Kyrgyz Republic provides the opportunity to determine fracture probability among the Kyrgyz population and help guide decisions about treatment.

Quality of life after fragility fracture in the Russian Federation: results from the Russian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (ICUROS)

Changes in health-related quality of life (QoL) due to hip, humeral, ankle, spine, and distal forearm fracture were measured in Russian adults age 50 years or more over the first 18 months after fracture. The accumulated mean QoL loss after hip fracture was 0.5 and significantly greater than after fracture of the distal forearm (0.13), spine (0.21), proximal humerus (0.26), and ankle (0.27).

INTRODUCTION

Data on QoL following osteoporotic fractures in Russia are scarce. The present study evaluated the impact of hip, vertebral, proximal humerus, distal forearm, and ankle fracture up to 18 months after fracture from the Russian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study.

METHODS

Individuals age ≥ 50 years with low-energy-induced humeral, hip, clinical vertebral, ankle, or distal forearm fracture were enrolled. After a recall of pre-fracture status, HRQoL was prospectively collected over 18 months of follow-up using EQ-5D-3L. Multivariate regression analysis was used to identify determinants of QALYs loss.

RESULTS

At 2 weeks, patients with hip fracture (n = 223) reported the lowest mean health state utility value (HSUV) compared with other fracture sites. Thereafter, utility values increased but remained significantly lower than before fracture. For spine (n = 183), humerus (n = 166), and ankle fractures (n = 214), there was a similar pattern of disutility with a nadir within 2 weeks and a progressive recovery thereafter. The accumulated mean QoL loss after hip fracture was 0.5 and significantly greater than after fracture of the distal forearm (0.13), spine (0.21), proximal humerus (0.26), and ankle (0.27). Substantial impairment in self-care and usual activities immediately after fracture were important predictors of recovery across at all fracture sites.

CONCLUSIONS

Fractures of the hip, vertebral, distal forearm, ankle, and proximal humerus incur substantial loss of QoL in Russia. The utility values derived from this study can be used in future economic evaluations.

Epidemiology of osteoporotic fracture in Kazakhstan and development of a country specific FRAX model

Retrospective and prospective population-based survey in a region of the Republic of Kazakhstan determined the incidence of fractures at the hip, proximal humerus and distal forearm. The hip fracture rates were used to create a FRAX® model to enhance fracture risk assessment in Kazakhstan.

OBJECTIVE

This paper describes the epidemiology of osteoporotic fractures in the Republic of Kazakhstan that was used to develop a country specific FRAX® tool for fracture prediction.

METHODS

We carried out a retrospective population-based survey in Taldykorgan in the Republic of Kazakhstan representing approximately 1% of the country's population. Hip, forearm and humerus fractures were identified retrospectively in 2015 and 2016 from hospital registers and the trauma centre. Hip fractures were prospectively identified in 2017 from the same sources and additionally from primary care data. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Kazakhstan. Fracture probabilities were compared with those from neighbouring countries having FRAX models.

RESULTS

The difference in hip fracture incidence between the retrospective and prospective survey indicated that approximately 25% of hip fracture cases did not come to hospital attention. The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 11,690 and is predicted to increase by 140% to 28,000 in 2050. Hip fracture incidence was a good predictor of forearm and humeral fractures in men but not in women.

CONCLUSION

The FRAX model should enhance accuracy of determining fracture probability among the Kazakh population and help guide decisions about treatment.

Epidemiology of hip fracture and the development of a FRAX model for Uzbekistan

A prospective population-based survey in a region of the Republic of Uzbekistan determined the incidence of fractures at the hip. The hip fracture rates were used to create a FRAX® model to facilitate fracture risk assessment in Uzbekistan.

OBJECTIVE

This paper describes the epidemiology of hip fracture in the Republic of Uzbekistan that was used to develop a country-specific FRAX® tool for fracture prediction.

METHODS

During a 1-year (2016/17) prospective population-based survey in the Pap district of the Republic of Uzbekistan, hip fractures were prospectively identified from hospital registers, trauma centres and primary care and community sources. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Uzbekistan. Fracture probabilities were compared with those from neighbouring Kazakhstan and Kyrgystan.

RESULTS

Approximately 41% of hip fracture cases did not come to medical attention, and two thirds of patients overall were not admitted to hospital. The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 16,764 and is predicted to increase more than three-fold to 60,272 in 2050. FRAX-based probabilities were higher in Uzbekistan than Kazakhstan or Kyrgystan.

CONCLUSION

The FRAX model should enhance accuracy of determining fracture probability among the Uzbek population and help guide decisions about treatment.

Epidemiology of hip fracture in Belarus: development of a country-specific FRAX model and its comparison to neighboring country models

Fracture probabilities resulting from the newly generated FRAX model for Belarus based on regional estimates of the hip fracture incidence were compared with FRAX models of neighboring countries. Differences between the country-specific FRAX patterns and the rank orders of fracture probabilities were modest.

OBJECTIVE

This paper describes the epidemiology of hip fractures in Belarus that was used to develop the country-specific fracture prediction FRAX® tool and illustrates its features compared to models for the neighboring countries of Poland, Russia, and Lithuania.

METHODS

We carried out a population-based study in a region of Belarus (the city of Mozyr) representing approximately 1.2% of the country's population. We aimed to identify all hip fractures in 2011-2012 from hospital registers and primary care sources. Age- and sex-specific incidence and national mortality rates were incorporated into a FRAX model for Belarus. Fracture probabilities were compared with those derived from FRAX models in neighboring countries.

RESULTS

The estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 8250 in 2015 and is predicted to increase to 12,918 in 2050. The annual incidence of fragility hip fractures in individuals aged 50 years or more was 24.6/10,000 for women and 14.6/10,000 for men, standardized to the world population. The comparison with FRAX models in neighboring countries showed that hip fracture probabilities in men and women in Belarus were similar to those in Poland, Russia, and Lithuania. The difference in incidence rates between the surveys including or excluding data from primary care suggested that 29.1% of patients sustaining a hip fracture were not hospitalized and, therefore, did not receive specialized medical care.

CONCLUSION

A substantial proportion of hip fractures in Belarus does not come to hospital attention. The FRAX model should enhance accuracy of determining fracture probability among the Belarus population and help guide decisions about treatment.

Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures-results from the ICUROS

This study used data from the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) to estimate the quality of life (QoL) impact of fracture. Hip, vertebral, and distal forearm fractures incur substantial QoL losses. Hip and vertebral fracture results in markedly impaired QoL for at least 18 months.

INTRODUCTION

The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) is a multinational observational study that aims to describe costs and quality of life (QoL) consequences of osteoporotic fractures. To date, 11 countries have participated in the study: Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, the UK, and the USA. The objective of this paper is to describe the QoL impact of hip, vertebral, and distal forearm fracture.

METHODS

Data were collected at four time-points for five QoL point estimates: within 2 weeks after fracture (including pre-fracture recall) and at 4, 12, and 18 months after fracture. Quality of life was measured as health state utility values (HSUVs) derived from the EQ-5D-3L. Complete case analysis was conducted as the base case with available case and multiple imputation performed as sensitivity analyses. Multivariate analysis was performed to explore predictors of QoL impact of fracture.

RESULTS

Among 5456 patients enrolled using convenience sampling, 3021 patients were eligible for the base case analysis (1415 hip, 1047 distal forearm, and 559 vertebral fractures). The mean (SD) difference between HSUV before and after fracture for hip, vertebral, and distal forearm fracture was estimated at 0.89 (0.40), 0.67 (0.45), and 0.48 (0.34), respectively (p < 0.001 for all fracture types). Eighteen months after fracture, mean HSUVs were lower than before the fracture in patients with hip fracture (0.66 vs. 0.77 p < 0.001) and vertebral fracture (0.70 vs. 0.83 p < 0.001). Hospitalization and higher recalled pre-fracture QoL were associated with increased QoL impact for all fracture types.

CONCLUSIONS

Hip, vertebral, and distal forearm fractures incur substantial loss in QoL and for patients with hip or vertebral fracture, QoL is markedly impaired for at least 18 months.

Patterns in the Diagnosis and Treatment of Osteoporosis in Men: A Questionnaire-based Survey in Central and Eastern European Countries

To assess the current practice patterns in the diagnosis and treatment of male osteoporosis based on questionnaires. Questionnaires were presented and filled out by osteoporosis experts from Austria, Bulgaria, the Czech Republic, Hungary, Poland, Romania, Slovakia, Slovenia and Russia. The questions included focused on the proportion of male referrals to DXA, the main reasons for referral, the preferred measurement sites and reference database, the definition of male osteoporosis, needed laboratory investigations, data on calcium and vitamin D supplementation as well as on treatment modalities and their reimbursement rate. Men comprised 5 to 10% of all DXA referrals. The main reasons for referral were low back pain and fractures. Most of the respondents used the International male reference database. The diagnosis of osteoporosis was based mainly on a T-score below −2.5 after the age of 50, but a few respondents added fractures as a necessary condition. Only 1/3 of men visiting DXA sites are expected to have normal BMD. A consensus for the use of laboratory investigations in male osteoporosis is practically lacking. Treatment modalities include alendronate, risedronate, zoledronate, denosumab, rhPTH and strontium (with some restrictions for the latter three). Data on treatment adherence and persistence are generally lacking except for Austria, Romania and Slovakia. The levels of reimbursement vary a lot across countries. Osteoporosis in men is an under-recognized problem in CEE countries, leading to a tremendous gap in the diagnosis and treatment.

Effect of twelve-month physical exercise program on patients with osteoporotic vertebral fractures: a randomized, controlled trial

We performed a randomized clinical trial to evaluate the effect of a 12-month physical exercise program on quality of life, balance, and functional mobility in postmenopausal women with osteoporotic vertebral fractures. All three outcomes improved in the intervention group and were better than in the controls.

INTRODUCTION

Th aim of this study was to evaluate the effectiveness of a structured physical exercise intervention on quality of life, functional mobility, and balance in patients with osteoporotic vertebral fractures and back pain.

METHODS

Seventy-eight postmenopausal women with vertebral fractures were randomized into an exercise group (n = 40) and a control group (n = 38). The mean age was 69.2 ± 7.7 years. All women had at least one osteoporotic vertebral fracture and suffered from chronic back pain. Patients with a history of vertebral and non-vertebral fracture within the past 6 months were excluded. The 40-min exercise program was conducted twice weekly for 1 year. Participants in the control group were instructed to continue their usual daily activities. Participants were assessed at baseline and at 12 months using the Quality of Life Questionnaire (QUALEFFO-41). Balance was measured with the Balance Master® System NeuroCom® and functional mobility was measured with the "timed up and go" test and "sit-to-stand" test.

RESULTS

Total QUALEFFO-41 score after 12 months was significantly better in the exercise group (44.2 ± 7.5) compared to the control group (56.6 ± 9.4), p < 0.0001. Quality of life improved in domains: "Pain", "Physical function: Jobs around the house", "Physical function: Mobility", "Social function", "General health perception" in the exercise group as compared to the control group. After 12 months, balance as assessed by "Tandem Walk and Sway" became significantly better in the exercise group as compared to the control group (p = 0.02). A significant improvement in the "timed up and go" test (p = 0.02) and the "sit-to-stand" test (p = 0.01) was shown in the exercise group compared to the control group.

CONCLUSIONS

This is the first 12 month-randomized clinical trial of exercise in osteoporotic women with a vertebral fracture that demonstrates improvement of three key outcome measures: quality of life, functional mobility, and balance.

Trabecular bone score: a noninvasive analytical method based upon the DXA image

The trabecular bone score (TBS) is a gray-level textural metric that can be extracted from the two-dimensional lumbar spine dual-energy X-ray absorptiometry (DXA) image. TBS is related to bone microarchitecture and provides skeletal information that is not captured from the standard bone mineral density (BMD) measurement. Based on experimental variograms of the projected DXA image, TBS has the potential to discern differences between DXA scans that show similar BMD measurements. An elevated TBS value correlates with better skeletal microstructure; a low TBS value correlates with weaker skeletal microstructure. Lumbar spine TBS has been evaluated in cross-sectional and longitudinal studies. The following conclusions are based upon publications reviewed in this article: 1) TBS gives lower values in postmenopausal women and in men with previous fragility fractures than their nonfractured counterparts; 2) TBS is complementary to data available by lumbar spine DXA measurements; 3) TBS results are lower in women who have sustained a fragility fracture but in whom DXA does not indicate osteoporosis or even osteopenia; 4) TBS predicts fracture risk as well as lumbar spine BMD measurements in postmenopausal women; 5) efficacious therapies for osteoporosis differ in the extent to which they influence the TBS; 6) TBS is associated with fracture risk in individuals with conditions related to reduced bone mass or bone quality. Based on these data, lumbar spine TBS holds promise as an emerging technology that could well become a valuable clinical tool in the diagnosis of osteoporosis and in fracture risk assessment.

The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)--quality of life during the first 4 months after fracture

The quality of life during the first 4 months after fracture was estimated in 2,808 fractured patients from 11 countries. Analysis showed that there were significant differences in the quality of life (QoL) loss between countries. Other factors such as QoL prior fracture and hospitalisation also had a significant impact on the QoL loss.

INTRODUCTION

The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS) was initiated in 2007 with the objective of estimating costs and quality of life related to fractures in several countries worldwide. The ICUROS is ongoing and enrols patients in 11 countries (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, UK and the USA). The objective of this paper is to outline the study design of ICUROS and present results regarding the QoL (measured using the EQ-5D) during the first 4 months after fracture based on the patients that have been thus far enrolled ICUROS.

METHODS

ICUROS uses a prospective study design where data (costs and quality of life) are collected in four phases over 18 months after fracture. All countries use the same core case report forms. Quality of life was collected using the EQ-5D instrument and a time trade-off questionnaire.

RESULTS

The total sample for the analysis was 2,808 patients (1,273 hip, 987 distal forearm and 548 vertebral fracture). For all fracture types and countries, the QoL was reduced significantly after fracture compared to pre-fracture QoL. A regression analysis showed that there were significant differences in the QoL loss between countries. Also, a higher level of QoL prior to the fracture significantly increased the QoL loss and patients who were hospitalised for their fracture also had a significantly higher loss compared to those who were not.

CONCLUSIONS

The findings in this study indicate that there appear to be important variations in the QoL decrements related to fracture between countries.

A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis

This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for 3 months or longer.

INTRODUCTION

The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010.

METHODS AND RESULTS

The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review.

CONCLUSIONS

Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.

Epidemiology of fracture in the Russian Federation and the development of a FRAX model

The incidence of hip, forearm and humeral fractures was studied in two cities from the Russian Federation. Fracture rates were used to create a FRAX model for Russia and to estimate the current and future burden of fracture.

PURPOSE

There is scant information on the epidemiology of fracture in Russia. The aim of the study was to determine the incidence of major fractures in order to populate a new FRAX model and to characterise the burden and future burden of fractures.

METHODS

The number of hip, forearm and humeral fractures was determined in two Russian cities with a well-defined catchment population over a 2-3-year period. Incidence rates for the two cities were merged and used to populate a FRAX model for Russia. Incidence rates were also applied to the general population in 2010 and 25 years later in 2035.

RESULTS

A total of 6,012 fractures were documented. For hip fracture, 27 % of cases in Pervouralsk and 1.8 % in Yaroslavl were not registered in the hospital data base. The incidence of index fractures increased with age and was higher in women than in men. The lifetime probability of hip fracture at the age of 50 years was 4 % in men and 7 % in women. The total number of hip fractures estimated in 2010 (112,000) is expected to rise to 159,000 in 2035. The estimated number of major fractures will rise from 590,000 to 730,000 over the same time interval.

CONCLUSIONS

Fragility fractures pose a serious health care problem in Russia. Urgent steps are needed to improve the acute management of hip fracture and long-term care of other osteoporotic fractures.

An appendix to the 2012 IOF-ECTS guidelines for the management of glucocorticoid-induced osteoporosis

The use of glucocorticoids in the treatment of medical disorders can lead to rapid bone loss and increased risk of fragility fracture. Updated clinical guidelines are needed that accommodate recent advances in fracture risk assessment and new pharmacological interventions to reduce fracture risk. This document serves as an appendix to the 2012 IOF-ECTS guidelines for the management of glucocorticoid-induced osteoporosis.

Official Positions for FRAX® clinical regarding international differences from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®

Osteoporosis is a serious worldwide epidemic. Increased risk of fractures is the hallmark of the disease and is associated with increased morbidity, mortality and economic burden. FRAX® is a web-based tool developed by the Sheffield WHO Collaborating Center team, that integrates clinical risk factors, femoral neck BMD, country specific mortality and fracture data and calculates the 10 year fracture probability in order to help health care professionals identify patients who need treatment. However, only 31 countries have a FRAX® calculator at the time paper was accepted for publication. In the absence of a FRAX® model for a particular country, it has been suggested to use a surrogate country for which the epidemiology of osteoporosis most closely approximates the index country. More specific recommendations for clinicians in these countries are not available. In North America, concerns have also been raised regarding the assumptions used to construct the US ethnic specific FRAX® calculators with respect to the correction factors applied to derive fracture probabilities in Blacks, Asians and Hispanics in comparison to Whites. In addition, questions were raised about calculating fracture risk in other ethnic groups e.g., Native Americans and First Canadians. In order to provide additional guidance to clinicians, a FRAX® International Task Force was formed to address specific questions raised by physicians in countries without FRAX® calculators and seeking to integrate FRAX® into their clinical practice. The main questions that the task force tried to answer were the following: The Task Force members conducted appropriate literature reviews and developed preliminary statements that were discussed and graded by a panel of experts at the ISCD-IOF joint conference. The statements approved by the panel of experts are discussed in the current paper.

Eprodisate for the treatment of renal disease in AA amyloidosis

BACKGROUND

Amyloid A (AA) amyloidosis is a complication of chronic inflammatory conditions that develops when proteolytic fragments of serum amyloid A protein (SAA) are deposited in tissues as amyloid fibrils. Amyloid deposition in the kidney causes progressive deterioration in renal function. Eprodisate is a member of a new class of compounds designed to interfere with interactions between amyloidogenic proteins and glycosaminoglycans and thereby inhibit polymerization of amyloid fibrils and deposition of the fibrils in tissues.

METHODS

We performed a multicenter, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of eprodisate in patients with AA amyloidosis and kidney involvement. We randomly assigned 183 patients from 27 centers to receive eprodisate or placebo for 24 months. The primary composite end point was an assessment of renal function or death. Disease was classified as worsened if any one of the following occurred: doubling of the serum creatinine level, reduction in creatinine clearance by 50% or more, progression to end-stage renal disease, or death.

RESULTS

At 24 months, disease was worsened in 24 of 89 patients who received eprodisate (27%) and 38 of 94 patients given placebo (40%, P=0.06); the hazard ratio for worsening disease with eprodisate treatment was 0.58 (95% confidence interval, 0.37 to 0.93; P=0.02). The mean rates of decline in creatinine clearance were 10.9 and 15.6 ml per minute per 1.73 m(2) of body-surface area per year in the eprodisate and the placebo groups, respectively (P=0.02). The drug had no significant effect on progression to end-stage renal disease (hazard ratio, 0.54; P=0.20) or risk of death (hazard ratio, 0.95; P=0.94). The incidence of adverse events was similar in the two groups.

CONCLUSIONS

Eprodisate slows the decline of renal function in AA amyloidosis. (ClinicalTrials.gov number, NCT00035334.)

Diagnostic performance of amyloid A protein quantification in fat tissue of patients with clinical AA amyloidosis

OBJECTIVE

Amyloid A protein quantification in fat tissue is a new immunochemical method for detecting AA amyloidosis, a rare but serious disease. The objective was to assess diagnostic performance in clinical AA amyloidosis.

METHODS

Abdominal subcutaneous fat tissue of patients with AA amyloidosis was studied at the start of an international clinical trial with eprodisate (NC-503; 1,3-propanedisulfonate; Kiacta), an antiamyloid compound. All patients had renal findings, i.e. proteinuria (> or =1 g/day) or reduced creatinine clearance (20 - 60 ml/min). Controls were patients with other types of amyloidosis and arthritic patients without amyloidosis. Amyloid A protein was quantified by ELISA using monoclonal antihuman serum amyloid A antibodies. Congo red stained slides were scored by light microscopy in a semiquantitative way (0 to 4+).

RESULTS

Ample fat tissue (>50 mg) was available for analysis in 154 of 183 patients with AA amyloidosis and in 354 controls. The sensitivity of amyloid A protein quantification for detection of AA amyloidosis (>11.6 ng/mg fat tissue) was 84% (95% CI: 77 - 89%) and specificity 99% (95% CI: 98 - 100%). Amyloid A protein quantification and semiquantitative Congo red scoring were concordant. Men had lower amyloid A protein values than women (p < 0.0001) and patients with familial Mediterranean fever had lower values than patients with arthritis (p < 0.001) or other inflammatory diseases (p < 0.01).

CONCLUSIONS

Amyloid A protein quantification in fat tissue is a sensitive and specific method for detection of clinical AA amyloidosis. Advantages are independence from staining quality and observer experience, direct confirmation of amyloid AA type, and potential for quantitative monitoring of tissue amyloid over time.

Vitamin D status among patients with hip fracture and elderly control subjects in Yekaterinburg, Russia

PURPOSE

Vitamin D deficiency leads to secondary hyperparathyroidism and osteomalacia, and both conditions are associated with fractures, the most severe being hip fracture. The serum 25-hydroxyvitamin D level depends on latitude and season. Yekaterinburg is situated at a high latitude and the duration of winter is about 5 months.

METHODS

In this study, the serum 25(OH)D and PTH concentrations, and the prevalence of hypovitaminosis D in elderly people, inhabitants of Yekaterinburg, were investigated. The study was performed on 63 people with hip fracture (mean age, 68.8 years) and 97 independently living elderly people (mean age, 70.2 years).

RESULTS

Serum 25(OH)D (mean+/-SD) in the hip fracture group was 22.4+/-11.4 nmol/L, significantly lower than in control group, which was 28.1+/-10.1 nmol/L. The percentage of patients with severe hypovitaminosis D (<25 nmol/L) in the hip fracture group was 65%, compared to 47% in the control group (p<0.05). The prevalence of hypovitaminosis D among hip fracture patients, as well as among independently living elderly people in Yekaterinburg, was high.

CONCLUSION

Supplementation of vitamin D in elderly people with and without fracture might prevent secondary hyperparathyroidism, osteomalacia and fractures.

Clinical features of Lyme borreliosis in the middle Urals and distribution of Borrelia burgdorferi sensu lato species in local Ixodes persulcatus ticks

From 1991 to 1993, we investigated the clinical features of Lyme borreliosis (LB) in 864 patients from the Sverdlovsk region (population 4.5 million) in the middle Urals. Ixodes persulcatus ticks were collected in the vicinity of Yekaterinburg to determine the presence of Borrelia burgdorferi sensu lato species. From 1991 to 1993, the number of patients with LB increased from 91 to 320 and 453, respectively. Nearly all LB patients (97%) recalled a tick bite and the first signs of LB developed between May and August. Erythema migrans (EM) was seen in 820 patients (94.9%) and fever was common (44.6%). Neuroborreliosis, mainly radiculoneuritis, was found in 154 patients (17.8%), secondary erythema was seen in 53 patients, and Lyme arthritis (LA) was diagnosed in 35 patients. Carditis was rare and acordermatitis chronica atrophicans (ACA) was not seen. Only 44 patients developed one or more symptoms of LB without a preceding EM. Few patients were seropositive for tick-borne encaphalitis. Borrelial DNA was detected in 67% of I. persulcatus ticks. Infected ticks carried predominantly Borrelia garinii or Borrelia afzelii, mixed infections of both species were common. Borrelia valaisiana was detected once, and B. burgdorferi sensu stricto was not found. Although the course of LB in the middle Urals in comparable to that of European LB, several discrepancies were noted. LB patients often recall tick bites, fever is common, LA is mild and ACA is absent.

Does chlamydia trachomatis influence manifestations of Lyme Arthritis?

Lyme arthritis, caused by the tick-borne spirochete Borrelia burgdorferi, produces typically intermittent episodes of arthritis of the larger joints, usually the knee joints. A number of patients, however, develop arthritis more closely resembling Reiter's syndrome, i.e., heel and ankle involvement. We studied the clinical features of ten patients who developed arthritis after a tick bite and who had shown erythema migrans and related it to the presence of evidence of Chlamydia trachomatis infection. Along with typical signs of Lyme arthritis we observed heel and ankle involvement. Chlamydia trachomatis was found in smears in 4 cases, whereas no patient had antichlamydial antibodies. However, evidence of Chlamydia trachomatis did not correlate with signs considered typical of Reiter's syndrome. Therefore, Lyme arthritis may have some arthritic manifestations resembling Reiter's syndrome, but this seems unrelated to the presence of Chlamydia trachomatis. Moreover, the arthritis is not associated with HLA-B27.