Estimate Fracture Risk Research Articles

Additional tools for the estimation of fracture risk using DXA method

Additional tools for the estimation of fracture risk using DXA method

Parathyroid Hormone-Related Changes of Bone Structure.

Parathyroid hormone (PTH) increases the release of serum calcium through osteoclasts, which leads to bone resorption. Primary, PTH stimulates osteoblasts leading to increase RANKL (receptor activator for nuclear factor kappa-B ligand) expression and thus differentiation of osteoclasts. In kidneys, PTH increases calcium and decrease phosphate reabsorption. In kidneys, PTH stimulates 1alpha-hydroxylase to synthesize active vitamin D. Primary hyperparathyroidism (PHPT) is characterized by skeletal or renal complications. Nowadays, the classical form of PHPT is less seen and asymptomatic or subclinical (oligo symptomatic) forms are more frequent. Previously, it was thought that cortical bone is preferably affected by PHPT and that predispose bones to fracture at sites with a higher amount of cortical bone. However, an increased risk of vertebral fractures has been found by most of the studies showing that also trabecular bone is affected. Bone Mass measurement (BMD) at all skeletal sites is advised, but another specific tool for fracture assessment is needed. Trabecular bone score (TBS), an indirect measure of trabecular bone, maybe a useful method to estimate fracture risk. TBS is associated with vertebral fractures in PHPT regardless of BMD, age, BMI and gender. Furthermore, there is an association between TBS and high resolution peripheral quantitative computed tomography (HR-pQCT) parameters in the trabecular and cortical compartment. However, studies considering the effect of PHPT treatment on TBS are more conflicting. Secondary hyperparathyroidism caused by vitamin D deficiency was associated with impaired bone microarchitecture in all age categories, as measured by TBS and Hr-pQCT with further improvement after treatment with vitamin D.

Predictive performance of the Garvan Fracture Risk Calculator: a registry-based cohort study.

The optimal model for fracture risk estimation to guide treatment decision-making remains controversial. Our objective was toevaluate the predictive performance of the Garvan Fracture Risk Calculator (FRC) in a large clinical registry from Manitoba, Canada. Using the population-based Manitoba Bone Mineral Density (BMD) registry, we identified women and men aged 50-95years undergoing baseline BMD assessment from September 1, 2012, onwards. Five-year Garvan FRC predictions were generated from clinical risk factors (CRFs) with and without femoral neck BMD. We identified incident non-traumatic osteoporotic fractures (OFs) and hip fractures (HFs) from population-based healthcare data sources to March 31, 2018. Fracture risk was assessed from area under the receiver operating characteristic curve (AUROC). Cox regression analysis and calibration ratios (5-year observed/predicted) were assessed for risk quintiles. All analyses were sex stratified. We included 16,682 women (mean age 66.6 + / - SD 8.7years) and 2839 men (mean age 68.7 + / - SD 10.2years). During a mean observation time of 2.6years, incident OFs were identified in 681 women and 140 men and HFs in 199 women and 22 men. AUROC showed significant fracture risk stratification with the Garvan FRC. Tool predictions without BMD were better than from age or decreasing weight, and the tool with BMD performed better than BMD alone. Garvan FRC with BMD performed better than without BMD, especially for HF prediction (AUROC 0.86 in women, 0.82 in men). There was a strong gradient of increasing risk across Garvan FRC quintiles (highest versus lowest, hazard ratios women 5.75 and men 3.43 for any OF; women 101.6 for HF). Calibration differences were noted, with both over- and underestimation in risk. Garvan FRC outperformed CRFs and BMD alone for fracture risk stratification, particularly for HF, but may require recalibration for accurate predictions in this population.

Bariatric surgery increases the rate of major fracture: self-controlled case series study in UK Clinical Practice Research Datalink.

ABSTRACTConflicting results exist about the relationship between bariatric surgery and fracture risk. Also, prediction of who is at increased risk of fracture after bariatric surgery is not currently available. Hence, we used a combination of a self‐controlled case series (SCCS) study to establish the association between bariatric surgery and fracture, and develop a prediction model for postoperative fracture risk estimation using a cohort study. Patients from UK Primary care records from the Clinical Practice Research Datalink GOLD linked to Hospital Episode Statistics undergoing bariatric surgery with body mass index (BMI) ≥30 kg/m2 between 1997 and 2018 were included in the cohort. Those sustaining one or more fractures in the 5 years before or after surgery were included in the SCCS. Fractures were considered in three categories: (i) any except skull and digits (primary outcome); (ii) major (hip, vertebrae, wrist/forearm, and humerus); and (iii) peripheral (forearm and lower leg). Of 5487 participants, 252 (4.6%) experienced 272 fractures (of which 80 were major and 135 peripheral) and were included in the SCCS analyses. Major fracture risk increased after surgery, incidence rate ratios (IRRs) and 95% confidence intervals (CIs): 2.77 (95% CI, 1.34–5.75) and 3.78 (95% CI, 1.42–10.08) at ≤3 years and 3.1 to 5 years postsurgery when compared to 5 years prior to surgery, respectively. Any fracture risk was higher only in the 2.1 to 5 years following surgery (IRR 1.73; 95% CI, 1.08–2.77) when compared to 5 years prior to surgery. No excess risk of peripheral fracture after surgery was identified. A prediction tool for major fracture was developed using 5487 participants included in the cohort study. It was also internally validated (area under the receiver‐operating characteristic curve [AUC ROC] 0.70) with use of anxiolytics/sedatives/hypnotics and female as major predictors. Hence, major fractures are nearly threefold more likely after bariatric surgery. A simple prediction tool with five variables identifies high risk patients for major fracture. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Dietary patterns and hip fracture in the Adventist Health Study 2: combined vitamin D and calcium supplementation mitigate increased hip fracture risk among vegans

Concerns regarding the adequacy of vegetarian diets with respect to fracture risk continue. We aimed to explore the influence of 5 previously defined dietary patterns on hip fracture risk and whether this association is modified by concomitant calcium and vitamin D supplementation. The Adventist Health Study 2 is a prospective cohort study in which participants were enrolled during 2002-2007; proportional hazards regression analyses were used to estimate fracture risk. Participants reside throughout the United States and Canada. A total of 34,542 non-Hispanic white peri- and postmenopausal women and men 45 y and older responded to the biennial hospital history form and were followed for a median of 8.4 y. The study identified 679 incident hip fractures during 249,186 person-years of follow-up. Fracture risk varied according to dietary pattern, with a clear effect modification by concurrent supplementation with both vitamin D and calcium. In multivariable models, including adjustment for calcium and vitamin D supplementation, female vegans had 55% higher risk of hip fracture (HR: 1.55; 95% CI: 1.06, 2.26) than nonvegetarians (NVEGs), whereas there was no association between diet pattern and hip fracture risk in men. When further stratifying females on supplement use with both vitamin D and calcium, vegans taking both supplements were at no greater risk of hip fracture than the subjects with other dietary patterns including the NVEGs. Without combined supplementation of both vitamin D and calcium, female vegans are at high risk of hip fracture. However, with supplementation the excessive risk associated with vegans disappeared. Further research is needed to confirm the adequacy of a vegan diet supplemented with calcium and vitamin D with respect to risk of fracture.

Characterization of Structural Bone Properties through Portable Single-Sided NMR Devices: State of the Art and Future Perspectives.

Nuclear Magnetic Resonance (NMR) is a well-suited methodology to study bone composition and structural properties. This is because the NMR parameters, such as the relaxation time, are sensitive to the chemical and physical environment of the 1H nuclei. Although magnetic resonance imaging (MRI) allows bone structure assessment in vivo, its cost limits the suitability of conventional MRI for routine bone screening. With difficulty accessing clinically suitable exams, the diagnosis of bone diseases, such as osteoporosis, and the associated fracture risk estimation is based on the assessment of bone mineral density (BMD), obtained by the dual-energy X-ray absorptiometry (DXA). However, integrating the information about the structure of the bone with the bone mineral density has been shown to improve fracture risk estimation related to osteoporosis. Portable NMR, based on low-field single-sided NMR devices, is a promising and appealing approach to assess NMR properties of biological tissues with the aim of medical applications. Since these scanners detect the signal from a sensitive volume external to the magnet, they can be used to perform NMR measurement without the need to fit a sample inside a bore of a magnet, allowing, in principle, in vivo application. Techniques based on NMR single-sided devices have the potential to provide a high impact on the clinical routine because of low purchasing and running costs and low maintenance of such scanners. In this review, the development of new methodologies to investigate structural properties of trabecular bone exploiting single-sided NMR devices is reviewed, and current limitations and future perspectives are discussed.

The break in FRAX: Equity concerns in estimating fracture risk in racial and ethnic minorities.

Journal of the American Geriatrics SocietyVolume 69, Issue 9 p. 2692-2695 Commentary The break in FRAX: Equity concerns in estimating fracture risk in racial and ethnic minorities Correction(s) for this article Erratum Volume 70Issue 6Journal of the American Geriatrics Society pages: E20-E20 First Published online: October 14, 2021 Hadley W. Reid MHS, Hadley W. Reid MHS Duke University School of Medicine , Durham, North Carolina, USASearch for more papers by this authorBharathi Selvan BA, Bharathi Selvan BA Duke University School of Medicine , Durham, North Carolina, USASearch for more papers by this authorBryan C. Batch MD, MHS, Bryan C. Batch MD, MHS Department of Medicine, Division of Endocrinology, Duke University School of Medicine, Durham, North Carolina, USASearch for more papers by this authorRichard H. Lee MD, MPH, Corresponding Author Richard H. Lee MD, MPH r.lee@duke.edu orcid.org/0000-0002-6909-4418 Department of Medicine, Division of Endocrinology, Duke University School of Medicine, Durham, North Carolina, USA Correspondence Richard H. Lee, Department of Medicine, Division of Endocrinology, Duke University School of Medicine, Durham, NC 27710, USA. Email: r.lee@duke.eduSearch for more papers by this author Hadley W. Reid MHS, Hadley W. Reid MHS Duke University School of Medicine , Durham, North Carolina, USASearch for more papers by this authorBharathi Selvan BA, Bharathi Selvan BA Duke University School of Medicine , Durham, North Carolina, USASearch for more papers by this authorBryan C. Batch MD, MHS, Bryan C. Batch MD, MHS Department of Medicine, Division of Endocrinology, Duke University School of Medicine, Durham, North Carolina, USASearch for more papers by this authorRichard H. Lee MD, MPH, Corresponding Author Richard H. Lee MD, MPH r.lee@duke.edu orcid.org/0000-0002-6909-4418 Department of Medicine, Division of Endocrinology, Duke University School of Medicine, Durham, North Carolina, USA Correspondence Richard H. Lee, Department of Medicine, Division of Endocrinology, Duke University School of Medicine, Durham, NC 27710, USA. Email: r.lee@duke.eduSearch for more papers by this author First published: 14 June 2021 https://doi.org/10.1111/jgs.17316 Funding information: National Center for Advancing Translational Sciences, Grant/Award Number: TL1 TR002555 Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume69, Issue9September 2021Pages 2692-2695 RelatedInformation

The impact of advanced glycation end products on bone properties in chronic kidney disease.

Chronic kidney disease (CKD) affects over 15% of Americans and results in an increased risk of skeletal fractures and fracture-related mortality. However, there remain great challenges in estimating fracture risk in CKD patients, as conventional metrics such as bone density assess bone quantity without accounting for the material quality of the bone tissue. The purpose of this review is to highlight the detrimental effects of advanced glycation end products (AGEs) on the structural and mechanical properties of bone, and to demonstrate the importance of including bone quality when assessing fracture risk in CKD patients. Increased oxidative stress and inflammation drive the production of AGEs in CKD patients that form nonenzymatic crosslinks between type I collagen fibrils in the bone matrix. Nonenzymatic crosslinks stiffen and embrittle the bone, reducing its ability to absorb energy and resist fracture. Clinical measurement of AGEs is typically indirect and fails to distinguish the identity and properties of the various AGEs. Accounting for the impact of AGEs on the skeleton in CKD patients may improve our estimation of overall bone quality, fracture risk, and treatments to improve both bone quantity and quality by reducing AGEs in patients with CKD merit investigation in order to improve our understanding of the etiology of increased fracture risk.

Comparison of 2 fracture risk estimation processes in Alberta: a cross-sectional chart review

Background:In Canada, decisions regarding osteoporosis pharmacotherapy are based on estimated 10-year risk of osteoporotic fracture. We aimed to determine how frequently 2 common approaches (Canadian Association of Radiologists and Osteoporosis Canada [CAROC] tool and Fracture Risk Assessment Tool [FRAX]) produced different estimates and to seek possible explanations for differences.Methods:We conducted a cross-sectional chart review at a tertiary osteoporosis centre (Dr. David Hanley Osteoporosis Centre in Calgary). Included patients were women referred for consideration of osteoporosis pharmacotherapy who attended a consultation between 2016 and 2019 and whose charts contained 10-year osteoporotic fracture risk estimates using both the CAROC tool (based on bone mineral density [BMD] results) and FRAX (based on BMD results and clinically assessed fracture risk factors). Risk estimates provided on BMD reports (calculated with CAROC) and generated through osteoporosis clinic consultation (calculated with FRAX, including BMD) were categorized as low (< 10.0%), moderate (10.0%–19.9%) or high (≥ 20.0%). Estimates were considered discordant when they placed the patient in different risk categories.Results:Of 190 patients evaluated, 99 (52.1%) had discordant risk estimates. Although a similar proportion were considered high risk by BMD reports using the CAROC tool (17.9%) and clinic charts using FRAX (19.5%), the 2 methods identified different patients as being high risk. Around the crucial high-risk (20.0%) treatment threshold, discordance was present in 37 patients (19.5%, 95% confidence interval [CI] 14.5%–25.7%); discordance around the moderate-risk (10.0%) threshold was present in 69 (36.3%, 95% CI 29.5%–43.2%) patients. Disagreement regarding fracture history between BMD reports and clinic charts was observed in 19.8% of patients.Interpretation:Fracture risk estimates on BMD reports (using the CAROC tool) and those calculated in the clinical setting (using FRAX) frequently result in different risk classification. Osteoporosis treatment decisions may differ in up to half of patients depending on which estimate is used, highlighting the need for a consistent and accurate assessment process for fracture risk.

Variation in fracture risk estimation among East Asian women.

Bone mineral density (BMD) testing and fracture risk calculation help clinicians assess fracture risk and counsel patients. However, predicted fracture risks and outcomes for US East Asian individuals remain understudied. Retrospective cohort study. Using standardized clinical profiles for East Asian women aged 70 years, fracture probabilities were estimated using the US Fracture Risk Assessment Tool (FRAX) version 4.1 and corresponding FRAX tools for East Asian countries. Next, clinical and BMD data from 3785 US Asian women aged 65 to 74 years were used to estimate 10-year hip fracture risk (US-Asian FRAX-v3.1) in comparison with actual observed 10-year hip fracture risk (Kaplan-Meier product limit estimate). For the same patient profile entered in the US-Asian FRAX and country-specific FRAX, the calculated 10-year hip fracture probability varied. Compared with the US-Asian FRAX calculator, the estimate was 2-fold higher using the Taiwan FRAX and Hong Kong FRAX, somewhat higher using the South Korea FRAX and Japan FRAX, and similar using the China FRAX. Among 3785 US Asian women (mean [SD] age, 69 [3] years), 23 experienced a hip fracture during a median follow-up of 6.8 years. Their observed 10-year hip fracture risk was 1.5% (95% CI, 0.8%-2.7%), and their median (interquartile range) predicted fracture probability (US-Asian FRAX-v3.1) was 1.1% (0.6%-2.0%). Country-specific FRAX estimates varied between the United States and East Asian countries. For US Asian women, the US FRAX-predicted hip fracture probabilities were in the lower range of observed risk. Although these findings support the use of the US-Asian FRAX for hip fracture risk assessment in US East Asian women, further studies are needed, including the examination of Asian subgroups.

Fracture Risk Assessment in Atypical Parkinsonian Syndromes

ABSTRACTBackgroundBone health and fracture risk reduction are increasingly recognized as important issues in Parkinson's disease (PD). However, the evidence for fracture risk management in atypical parkinsonism (AP) is less clear. Guidance on management of bone health in PD has recently been published.ObjectivesTo evaluate the outcome of fracture risk assessment in a cohort of patients with AP, compared to a population with idiopathic PD.MethodsWe did a cross‐sectional study of patients with PD or AP who had fracture risk assessed at two tertiary movement disorder centres. Data on fracture risk as assessed using QFracture and FRAX were collected. To assess for the effect of age on fracture risk we compared the risks of PD and AP patients aged ≤70 and >70 years.ResultsWe assessed 71 patients with AP and 267 with PD. Age, sex and body mass index were similar between groups; patients with AP were more likely to have fallen in the previous year. Major osteoporotic fracture risk was greater in patients with AP aged ≤70 compared to PD; no differences between groups were seen in those aged >70 years. 76% of those with AP, and 63% with PD, had an estimated fracture risk indicating bone‐sparing treatment, but only 33% of patients with AP were receiving this where it was indicated.ConclusionThere is scope for considerable improvement in fracture risk assessment and treatment in atypical parkinsonism, taking into account the worse prognosis of this patient group.

Pharmacotherapy decisions among postmenopausal women attending a group medical consultation or a one-on-one specialist consultation at an osteoporosis center: an observational cohort study.

Group medical consultations for osteoporosis are time-efficient and highly accepted by patients, but effects on treatment decisions are unknown. We aimed to compare women's decisions to initiate or decline osteoporosis pharmacotherapy after attending either a group or transitional one-on-one osteoporosis consultation. In this observational study, we prospectively evaluated postmenopausal women referred to an osteoporosis clinic who attended a group medical visit and compared their decisions regarding pharmacologic osteoporosis treatment with retrospective data from a cohort of women who attended a traditional consultation. Both consultation types involved interaction with a specialist physician, individualized fracture risk estimation (using FRAX®), and education regarding fracture consequences and available osteoporosis medications. Both forms of consultation emphasized shared decision-making; however, group consultation attendees did not receive personalized treatment recommendations from the physician. We reviewed the records of 125 women (median age 63 years) who attended a group consultation and 83 women (median age 64 years) who attended a traditional consultation between 2016 and 2019. Twenty-four (19%) of the group cohort and 16 (19%) of the traditional cohort were at high 10-year risk of major osteoporotic fracture (FRAX® ≥ 20.0%). A similar proportion planned to initiate pharmacologic therapy after the group and traditional consultations (23% vs 16%, p = 0.22); these proportions were comparable among women at high risk (42% vs 50%, p = 0.75) and moderate risk (19% vs 15%, p = 0.77), but a higher proportion of low-risk women planned to initiate therapy after the group consultation (18% vs 0%, p = 0.009). Patient decisions to initiate pharmacologic treatment made during a group visit are similar to those made during traditional one-on-one consultation. The group consultation model represents an alternative to one-on-one assessment for delivering osteoporosis consultative services.

The role of trabecular bone score, inaddition to FRAX, for the measurementof fracture risk in patients withdegenerative lumbar spine stenosis

Objectives: To investigate the relevance of Concomitant Trabecular Bone Score (TBS) and Areal Bone Mineral Density (aBMD) assessments to estimate fracture risk in patients with Degenerative Lumbar Spine Stenosis (DLSS). Methods: A cross-sectional prospective study was performed. Dual energy X-ray absorptiometry scans of the lumbar spine and hip were acquired in 50 patients with DLSS. TBS and aBMD were calculated from the anteroposterior views of L1-L4 vertebrae. The World Health Organisation Fracture Risk Assessment Tool (FRAX) was utilised to estimate hip or Major Osteoporotic Fracture (MOF) risk. Results: L1-L4 TBS scores revealed degraded microarchitecture, (TBS ≤ 1.20), partially degraded microarchitecture (TBS >1.20 and <1.35) or normal appearances (TBS ≥ 1.35) in 9 (18%), 14 (28%) and 27 (54%) patients, respectively. L1-L4 aBMD assessment demonstrated osteoporosis (T-score ≤- 2.5), osteopenia (T-score between -1.1 and -2.4) or normal bone density in 15 (30%), 11 (22%) and 24 (48%) patients, respectively. There was no relationship seen between L1-L4 aBMD and TBS measurements (r = 0.046; p = 0.75). A negative relationship was observed between TBS and body mass index (r = -0.438; p = 0.001) andbetween L1-L4 aBMD and FRAX (r = -0.617; p < 0.001); the latter included MOF and risk of hip fracture (r = -0.497; p < 0.001).No relationship was observed between TBS and FRAX included MOF and risk of hip fracture (r = -0.118; p = 0.416 and r = -0.014; p = 0.926, respectively) Conclusion: In patients with DLSS, TBS is a reliable, strong and standalone indicator of fracture risk

The Interaction of Lean Body Mass With Fat Body Mass Is Associated With Vertebral Fracture Prevalence in Women With Early Breast Cancer Undergoing Aromatase Inhibitor Therapy.

ABSTRACTAromatase inhibitors (AIs) induce depletion of estrogen levels, causing bone loss and increased fracture risk in women with breast cancer. High‐fat body mass (FBM) emerged as an independent factor associated with the prevalence of morphometric vertebral fractures (VFs) in patients undergoing AIs. We explored the role of lean body mass (LBM) and the interaction of LBM with FBM in predicting the occurrence of VFs in postmenopausal women who were either AI‐naïve or AI‐treated. A total of 684 consecutive breast cancer patients were enrolled in this cross‐sectional study. Each woman underwent a dual‐energy X‐ray absorptiometry (DXA) scan, measuring bone mineral density (BMD), LBM, and FBM; VFs were assessed using a quantitative morphometric analysis of DXA images. After propensity score matching, the study population was restricted to 480 women, 240 AI‐naïve and 240 AI‐treated. We used multivariable logistic regression models to explore the associations between baseline characteristics, VF prevalence and the interaction between LBM, FBM and AI therapy. No interaction between LBM and AI therapy on VF prevalence was shown. Conversely, we reported a significant interaction between LBM, FBM and AI therapy (p = .0311). Among AI‐treated women having LBM below and FBM above or equal the median value, VF prevalence was numerically higher (15/31; 48.4%) than in other subgroups (VF prevalence: 35.7% in high‐LBM and low‐FBM group, 23.2% in high‐LBM and high‐FBM group, and 19.8% in low‐LBM and low‐FBM group). Among AI‐naïve women, the greatest VF proportion was observed in the subgroup with LBM and FBM below median value (25/92; 27.2%). This study suggests a synergism between LBM and FBM in predicting the morphometric VF in women with early breast cancer undergoing AIs. This observation is new and deserves further investigation. The assessment of body composition by DXA might be useful when estimating fracture risk in this population. © 2020 American Society for Bone and Mineral Research © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

Considering Race and Ethnicity in the Management of Bone Health

Considering Race and Ethnicity in the Management of Bone Health

Decreased lower-extremity muscle performance is associated with decreased hip bone mineral density and increased estimated fracture risk in community-dwelling postmenopausal women.

Postmenopausal women are at high risk for osteoporotic fractures. It has been shown that decreased lower-extremity muscle performance is associated with osteoporotic fractures. However, the relationship between muscle performance and bone mineral density in postmenopausal women is inconsistent in the literature. The present study was to investigate the relationship between lower-extremity muscle performance and BMD or estimated fracture risk in community-dwelling postmenopausal women. Two hundred forty-seven postmenopausal women aged 50-85years were recruited in the study. The short physical performance battery (SPPB) tool including the chair stand test (CST), gait speed test (GST), and balance test (BT) was used to determine lower-extremity functioning and the CST, GST, BT, and SPPB total scores were recorded. The BMD of lumbar spine (LSBMD), femoral neck (FNBMD), and total hip (THBMD) were measured by dual-energy X-ray absorptiometry (DXA), and the vertebral fracture was confirmed by lateral spine X-rays radiographs. In addition, patients' 10-year estimated major osteoporotic fracture risk (MOFR) and hip fracture risk (HFR) were assessed by the Fracture Risk Assessment Tool (FRAX). Linear regression analysis was used to analyze the association between muscle performance and BMD. The CST, GST, and SPPB total scores were positively associated with LSBMD, THBMD, and FNBMD before adjustment for age, height, and weight. The SPPB total score was positively associated with FNBMD and THBMD, but not with LSBMD after adjustment for age, height, and weight. The BT score was positively associated with FNBMD and THBMD, but not with LSBMD before and after adjustment for age, height, and weight. Moreover, the CST, GST, BT, and SPPB scores were negatively associated with the FRAX score. The lower-extremity muscle performance in community-dwelling postmenopausal women is positively associated with FNBMD and THBMD and negatively associated with the FRAX score.

New technologies in the evaluation of bone fragility and their application in endocrinology

Bone mineral density using dual-energy X-ray absorptiometry is the gold standard for the assessment of bone and an important predictor of fracture risk. However, most fragility fractures occur in people without densitometric osteoporosis, especially in endocrinological diseases. Fracture risk estimation tools such as FRAX have improved diagnostic sensitivity but do not include additional skeletal features. Bone microarchitecture research represents an improvement in the treatment of these patients. In this document members of the Mineral and Bone Metabolism Working Group of the Spanish Society of Endocrinology and Nutrition review new advances in dual-energy X-ray absorptiometry and other complex techniques for the study of bone microarchitecture as well as the available data on type 2 diabetes and parathyroid pathology.

Fracture risk among treatment-naïve postmenopausal women with osteopenia in Greece: results from the "ACROSS" study.

When evaluating a patient with low bone mineral density (BMD), fracture risk estimation is of paramount importance. Fracture risk assessment using the FRAX tool is the most common and most studied practice worldwide. The primary aim of the "ACROSS" study was to record the 10-year probability of major osteoporotic fractures and hip fractures, using the Greek version of the FRAX tool, in a rather representative population of 230 postmenopausal treatment-naïve women with osteopenia. Secondary aims of the study were to identify (1) the risk for fractures according to age and the years from menopause, (2) the proportion of patients qualifying for treatment according to the Greek cost-effective FRAX thresholds, and (3) the perception of both the patient and the treating physician regarding the estimated fracture risk. The mean 10-year risk was 10.7% ± 6.6 for major osteoporotic fractures and 3.4% ± 4.2 for hip fractures. For women up to 75years of age, the 10-year risk for major osteoporotic and hip fractures was 8.8% and 2.1%, respectively, while for women over 75years, the risk was 15.2% and 6.6%, respectively. Patients generally believed that they had low fracture risk independently of age, while the physicians considered that the risk increases with advancing age. According to the Greek-specific FRAX-based thresholds, the administration of osteoporosis treatment would be cost-effective for approximately one-third of the study population and nearly half of the subjects over 75years. Patients are not fully aware of their fracture risk.

Impact microindentation in men with impaired fasting glucose and type 2 diabetes.

Individuals with type 2 diabetes (T2DM) are at increased fracture risk, with bone mineral density (BMD) measurements underestimating risk. Impact microindentation (IMI), a technique that measures bone microindentation distances, expressed as bone material strength index (BMSi), may improve fracture risk estimation in individuals with T2DM. This study describes the relationship between BMSi and glycaemia status in men and makes a comparison with bone measures from dual energy X-ray absorptiometry (DXA). Participants were 340 men aged 33-96yr from the Geelong Osteoporosis Study. Impaired fasting glucose (IFG) was defined using fasting plasma glucose (FPG) between 5.5 and 6.9mmol/L. Diabetes was defined as FPG≥7.0mmol/L, use of antihyperglycemic medication and/or self-report. Two participants with type 1 diabetes were excluded. BMSi was measured using an OsteoProbe. Femoral neck (FNBMD) and lumbar spine (LSBMD) were measured using DXA (Lunar Prodigy) and trabecular bone score (TBS) was calculated (TBS iNsight Version 2.2). Using linear regression techniques, the relationship between glycaemia status and BMSi was evaluated, adjusting for other potential confounders (including lifestyle factors, clinical measurements and FNBMD). Glycaemia status was also considered as a binary variable (T2DM vs normoglycaemia and IFG). There were 234 (68.8%) men with normoglycaemia, 59 (17.4%) with IFG and 47 (13.8%) with diabetes. When considering glycaemia status as a binary variable, men with T2DM had lower mean BMSi compared to those without T2DM (normoglycaemia and IFG combined) (79.8; 95%CI 77.0-82.6 vs 83.0; 82.2-83.8 p=0.043) and this difference in BMSi was independent of FNBMD. No differences were observed for either FNBMD or LSBMD; however, TBS was lower (1.177; 1.121-1.233 vs 1.256; 1.240-1.272, p=0.015, independent of FNBMD). For glycaemia status considered in three groups, there were no differences in mean BMSi values between men with normoglycaemia, IFG and T2DM (82.9 (95%CI 82.0-83.8), 83.5 (81.8-85.2) and 79.8 (77.0-82.6), respectively; ANCOVA, p=0.104). Measures reflecting bone material properties and microarchitecture (BMSi and TBS) might be better than measures of bone mass (BMD) in identifying individuals with T2DM at risk of fracture.

Autonomy begets adherence: decisions to start and persist with osteoporosis treatment after group medical consultation.

Adherence and persistence with osteoporosis pharmacotherapy is low, possibly reflecting lack of confidence in physicians' treatment recommendations. We evaluated treatment decisions, decisional confidence, and 12-month treatment adherence among women who attended a group bone health consultation that fostered autonomous decision-making. We prospectively assessed postmenopausal women referred to an osteoporosis clinic who chose to attend a group medical visit in lieu of one-on-one consultation. The group visit was facilitated by a specialist physician and nurse, involving estimation of 10-year major osteoporotic fracture risk (using FRAX®) and extensive education regarding fracture consequences and potential advantages and disadvantages of pharmacotherapy. No direct advice was given by the specialist. Post-consult, participants made an autonomous decision regarding treatment intent and followed up with their family physician to enact their chosen plan. Intentions to initiate pharmacotherapy were assessed immediately post-consult. Treatment status and decisional confidence were evaluated 3 and 12 months later. Three-month treatment status was considered to reflect final treatment decision. Persistence was defined as proportion of participants on treatment at 3 months who remained treated at 12 months. One hundred one women (mean (SD) age, 62.7 years (5.8); median (IQR) FRAX®, 10.7% (8.3-17.6)) participated. Immediately post-consult, 27 (26.7%) intended to initiate treatment. At 3 months, 23 (22.8%) were treated, and at 12 months, 21 (91.3%) remained persistent. Of 89 questionnaire respondents at 12 months, 85 (95.5%) reported confidence in their treatment decision. When postmenopausal women are provided with individualized fracture risk estimates and enabled to make autonomous decisions regarding pharmacotherapy, ultimate decisions to receive treatment are made with confidence and result in high persistence at 12 months.