Risk Of Fragility Fractures Research Articles

Calcium and vitamin D supplements for the treatment and prevention of osteoporosis. Should it be widely used?

Osteoporosis is the most common age-related skeletal diseases, which is characterized by the rapid loss of bone mineral density and increased risk of fragility fractures. The social significance of osteoporosis is attributed to its complications, which increase disability and mortality rates mostly among older people. Inadequate dietary calcium intake and vitamin D deficiency are well-known risk factors for osteoporosis. Thus, for many years, calcium and vitamin D have been considered crucial in the prevention and treatment of osteoporosis. However, in recent years, the efficacy and safety of calcium and vitamin D have been questioned because some randomized clinical trials have reported only a weak positive effect of calcium with or without vitamin on reducing fragility fracture risks. On the contrary, besides the gastrointestinal side effects of calcium supplements and the risk of kidney stones related to the co-administration of calcium and vitamin D supplements, other recent data suggested that calcium supplementation has potential adverse cardiovascular effects. This study focused on the evidence regarding the possible usefulness for bone health and the potential harmful effects of calcium and/or calcium with vitamin D supplementation.

Drugs associated with incident fragility fractures in kidney transplant recipients.

The risk of fragility fractures is high in kidney transplant recipients, and steroids are reportedly a major cause. Other drugs known to induce fragility fractures have been studied in the general population but not in kidney transplant recipients. Here, we investigated the association between exposure over time to drugs that can injure bone (namely vitamin K antagonists, insulin, loop diuretics, proton pump inhibitors, opioids, selective serotonin reuptake inhibitors, antiepileptics and benzodiazepines) and incident fractures and changes over time in T-scores in this population. A total of 613 consecutive kidney transplant recipients were included between 2006 and 2019. Drug exposures and incident fractures during the study period were comprehensively documented, and dual-energy X-ray absorptiometry was performed regularly. The data were analyzed using Cox proportional hazards models with time-dependent covariates and linear mixed models. Incident fractures occurred in 63 patients, giving a fracture incidence of 16.9 per 1000 person-years. Exposures to loop diuretics [hazard ratio (95% confidence interval) 2.11 (1.17-3.79)] and opioids [5.94 (2.14-16.52)] were associated with incident fractures. Exposure to loop diuretics was associated with a decrease over time in the T-score for the lumbar spine (P=.022) and for the wrist (P=.028). This study suggests that the exposure to loop diuretics and opioids increases the risk of fracture in kidney transplant recipients.

Association of age, sex and race with prescription of anti-osteoporosis medications following low-energy hip fracture in a retrospective registry cohort.

Initiation of anti-osteoporosis medications after hip fracture lowers the risk of subsequent fragility fractures. Historical biases of targeting secondary fracture prevention towards certain groups may result in treatment disparities. We examined associations of patient age, sex and race with anti-osteoporosis medication prescription following hip fracture. A cohort of patients with a hip fracture between 2016-2018 was assembled from the American College of Surgeons National Surgical Quality Improvement Program registry. Patients on anti-osteoporosis medications prior to admission were excluded. Multivariable logistic regression was used to determine adjusted associations between patient age, sex and race and their interactions with prescription of anti-osteoporosis medications within 30 days of surgery. In total, 12,249 patients with a hip fracture were identified with a median age of 82 years (IQR: 73-87), and 67% were female (n = 8,218). Thirty days postoperatively, 26% (n = 3146) of patients had been prescribed anti-osteoporosis medication. A significant interaction between age and sex with medication prescription was observed (p = 0.04). Male patients in their 50s (OR:0.75, 95%CI:0.60-0.92), 60s (OR:0.81, 95%CI:0.70-0.94) and 70s (OR:0.89, 95%CI:0.81-0.97) were less likely to be prescribed anti-osteoporosis medication compared to female patients of the same age. Patients who belonged to minority racial groups were not less likely to receive anti-osteoporosis medications than patients of white race. Only 26% of patients were prescribed anti-osteoporosis medications following hip fracture, despite consensus guidelines urging early initiation of secondary prevention treatments. Given that prescription varied by age and sex, strategies to prevent disparities in secondary fracture prevention are warranted.

Abstract 98

Background: There is an increased risk of fragility fractures in patients with type 2 diabetes mellitus (T2DM). Bone mineral density (BMD) as measured by DEXAmay be increased despite poor quality of bone and thus FRAX may underestimate the risk of fractures in this population. HR-pQCT is a non-invasive imaging modality for assessment of volumetric BMD (vBMD) and microarchitecture of cancellous and cortical bones. Also the available data regarding the choice of anti-osteoporotic therapy in T2DM are based on either preclinical studies or posthoc/subgroup analysis of randomized controlled trials (RCTs) with no head-to-head comparison. We aim to compare the efficacy of the three most commonly used anti-osteoporotic medications, namely, teriparatide, zoledronate and denosumab, in a cohort of postmenopausal women with T2DM at a high risk of incident fragility fractures. Methods: Here we present the interim analysis after 6 months of an open-labelled randomised control trial of 120 postmenopausal women with T2DM enrolled for 18 months follow-up. Patients were randomised into 4 groups in 1:1:1:1 ratio, with group Areceiving teriparatide, group B receiving zoledronate, Group C receiving denosumab each along with calcium and vitamin D supplements and group D receiving only calcium and vitamin D supplements. The objective was to determine the effects of the anti-osteoporotic drugs on HR-pQCT parameters at the end of 6 months compared to at the time of enrolment. Results: 31 patients who completed their 6 months follow-up were included in the analysis, 8 in group A, 7 in group B and D and 9 in group C. There were no significant change in the vBMD amongst the groups at 6 months at both tibia (p = 0.075) and radius (p = 0.067). There was a decrease in the total vBMD in all the 4 groups at tibia. However at the radius, total vBMD increased in group B and decreased in the rest, however the intra-group changes were not significant. There was a statistically significant difference in trabecular spacing at tibia between group A (increased) and group C (decreased) (p = 0.031). There were no significant changes in other bone microarchitecture parameters. Conclusion: At the end of 6 months, there were no significant changes in volumetric BMD and bone microarchitecture at both tibia and radius amongst the groups except for trabecular spacing. Larger number of patients with longer follow-up would help in further understanding.

Bipolar Disorder and Bone Mineral Density Z-Scores in Relation to Clinical Characteristics and Lithium Medication

Bipolar disorder is associated with a long range of medical comorbidities, including migraine, diabetes, and cardiovascular disease. Bipolar disorder has also been associated with an increased risk of bone fractures. Osteoporosis is a reduction in bone mineral density, which leads to an increased risk for fragility fractures. Currently there is limited research on the association between bipolar disorder and osteoporosis. We aimed to study the association between high and low bone mineral density in relation to disease and treatment history in a sample of bipolar patients. We found that bipolar patients with high bone mineral density were more often on lithium medication, had a more active lifestyle and expressed lower current disease burden. Low mineral density was not associated with any of the addressed aspects of disease and treatment history. In conclusion our results support that patients on lithium treatment have higher bone mineral density; further studies are needed to address if lithium medication causes an increase in bone mineral density, and lowers the risk of bone fractures in bipolar disorder.

A surgical procedure to deliver a triphasic calcium-based implant material to address local bone loss and strengthen an osteoporotic proximal femur: a case report

Bone loss associated with the systemic skeletal disease osteoporosis results in weakened or fragile bone, the most serious consequence of which is fracture. A 67-year-old post-menopausal Caucasian woman presented with a diagnosis of osteoporosis by FRAX and DXA and a history of a fragility hip fracture. The patient was classified according to the latest guidance document for treating patients with post-menopausal osteoporosis from the International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis. The patient was at very high risk for major osteoporotic fracture, including hip fracture. This case report describes the use of a minimally invasive surgical procedure to address bone loss in the proximal femur associated with osteoporosis. Local osteo-enhancement procedure (LOEP), a minimally invasive surgical procedure, was performed using a triphasic calcium-based implant material, AGN1. LOEP was carried out under general anesthesia and fluoroscopic navigation. The area of bone loss in the proximal femur, the enhancement site, was identified, debrided, and irrigated to prepare it for low-pressure filling with AGN1 implant material. The patient recovered from the procedure without incident and was discharged without activity limitations after an overnight stay. X-ray imaging and DXA scans were used to evaluate implant material resorption and replacement with bone over a 3.25-year follow up. A significant and sustained increase in femoral neck and total hip BMD was observed (pre vs 3.25 years post-procedure: 0.546 vs 1.031 gm/cm2 and 0.628 vs 0.96 gm/cm2, respectively), which corresponded to a change in the patient’s T-score from the osteoporosis range to normal. Based on the use of T-scores to measure the risk of fragility fractures, and acknowledging the well-published limitations of doing so, the hip fracture risk of this patient was reduced from very high to low. This case report documents the use of this minimally invasive, targeted procedure to address hip fragility fracture (the most serious issue in the systemic disease osteoporosis), with AGN1 implant material used to replace bone lost in the proximal femur.

A New Index Based on Serum Creatinine and Cystatin C Can Predict the Risks of Sarcopenia, Falls and Fractures in Old Patients with Low Bone Mineral Density

As new screening tools for sarcopenia, the serum sarcopenia index (SI) and creatinine/cystatin C ratio (CCR) had not been confirmd in a population with a high fragility fracture risk. This study aimed to evaluate whether SI and CCR indicators are useful for diagnosing sarcopenia and to determine their prediction values for future falls and fractures. A total of 404 hospitalized older adults were enrolled in this longitudinal follow-up study (mean age = 66.43 ± 6.80 years). The receiver operating curve (ROC) was used to assess the diagnostic accuracy of SI and CCR. Backward-selection binary logistic regression was applied to develop the optimal models for the diagnosis of new falls and fractures. SI had a significantly higher area under the curve (AUC) than CCR for predicting sarcopenia. The optimal models had acceptable discriminative powers for predicting new falls and fractures. Lower SI and CCR are the independent risks for sarcopenia, new falls, and fractures in the low-BMD population. SI and CCR, as easily accessible biochemical markers, may be useful in the detection of sarcopenia and in predicting the occurrence of new falls and fractures in patients with low BMD who have not previously experienced falls or fractures. However, further external validations are required.

Improving Bone Health in Patients with Metastatic Prostate Cancer with the Use of Algorithm-Based Clinical Practice Tool.

Background: The bone health of patients with locally advanced and metastatic prostate cancer is at risk from treatment-related bone density loss and skeletal-related events from metastatic disease in bones. Evidence-based guidelines recommend using denosumab or zoledronic acid at bone metastasis-indicated dosages in the setting of castration-resistant prostate cancer with bone metastases and at the osteoporosis-indicated dosages in the hormone-sensitive setting in patients with a significant risk of fragility fracture. For the concerns of jaw osteonecrosis, a dental evaluation is recommended before starting bone-modifying agents. The literature review suggests a limited evidence-based practice for bone health with prostate cancer in the real world. Both under-treatment and inappropriate dosing of bone remodeling therapies place additional risks to bone health. An incomplete dental work up before starting bone-modifying agents increases the risk of jaw osteonecrosis. Methods: We created an algorithm-based clinical practice tool to minimize the deviation from evidence-based guidelines at our center and provide appropriate bone health care to our patients by ensuring indication-appropriate dosing and dental screening rates. This order set was incorporated into the electronic medical record system for ordering a bone remodeling agent for prostate cancer. The tool prompts the clinicians to follow the appropriate algorithm in a stepwise manner to ensure a pretreatment dental evaluation and use of the correct dosage of drugs. Results: We analyzed the data from Sept 2019 to April 2022 following the incorporation of this tool. 0/35 (0%) patients were placed on inappropriate bone modifying agent dosing, and dental health was addressed in every patient before initiating treatment. We compared the change in the practice of prescribing and noted a significant difference in the clinician’s practice while prescribing denosumab/zoledronic acid before and after implementation of this tool [incorrect dosing: 24/41 vs. 0/35 (p < 0.00001)]; and an improvement in pretreatment dental checkup before and after implementation of the tool was noted to be [missed dental evaluation:12/41 vs. 0/35 (p < 0.00001)]. Conclusion: We found that incorporating an evidence-based algorithm in the order set while prescribing bone remodeling agents significantly improved our institutional clinical practice of indication-appropriate dosing and dental screening rates, and facilitated high-quality, evidence-based care to our patients with prostate cancer.

Evaluation of Comprehensive Management Protocol for Reduction of the Risk of Fragility Fractures Among Osteoporosis Individuals, Visiting Teaching Hospital, Kolkata

Introduction: Fragility fracture from osteoporosis is a major challenging health problem in aging population in developing countries. In order to reduce the risk of development of osteoporotic fragility fractures authors made a study with high risk individuals, divided into two groups and a comprehensive management protocol had been offered in one group where as conventional management protocol had been offered in other to see the efficacy of such comprehensive management protocol to reduce the risk of occurring fragility fracture over at least three months period among the patients, attended in orthopaedic out patient department of state medical college, West Bengal. Methods: The authors selected 30 diagnosed osteoporosis clients of 50 to 90 years age as per inclusion and exclusion criteria, who attended in orthopaedic OPD in SSKM Hospital, Kolkata, West Bengal, India from 2021April to July2021, carrying highest risk factors of developing osteoporosis. Results: In experimental group, mean post test BMD score is higher than the mean pre test BMD, which is statistically significant as calculated t value is 3.666 at 14 df at 0.05 (p&lt;0.05) level of significances. It indicates that comprehensive management protocol is effective to increase the bone strength. Conclusion: The study of comparison of mean difference values of two groups conclude that comprehensive management protocol can reduce the risk of osteoporotic fracture much efficiently in compared to standard pharmaceutical treatment in a short span of time which is applicable for long term management of osteoporosis.

Micropetrosis – Occlusion of Osteocyte Lacunae

AbstractThis article summarizes the current knowledge on micropetrosis – osteocyte lacunar occlusion, while focusing on the latest data on osteocyte viability and diabetic bone disease. The lacunae are fluid-filled ellipsoid spaces where osteocytes reside within the mineralized matrix. During osteocyte lifetime, the lacunar space is kept in a non-mineralized state. However, a dying osteocyte appears to enable the initiation of lacunar mineralization – creating a fossil within the living tissue. Elevated frequencies of micropetrosis are observed with advanced age, but also type 1 diabetes mellitus. The latter is a common health threat to our society with rising numbers of patients suffering from the disease associated symptoms including a secondary type of osteoporosis with an elevated risk of fragility fractures. While the underlying mechanism of diabetic bone disease is not entirely understood, more evidence is pointing towards a combinatory effect of loss of bone mass and an impaired overall bone quality. The high number of micropetrotic osteocyte lacunae leads to a more brittle bone tissue prone to microcracking. Further investigations are required to determine the implications of elevated micropetrosis as a reliable target of bone fragility.

Severity of Albuminuria Increases Risk of Fragility Fractures Independent of eGFR: A Population-Based Analysis

Fragility fractures are common in end stage kidney disease. This study’s primary objective is to determine the association of albuminuria and fragility fractures of the hip, pelvis, vertebrae, wrist, humerus and any site. Secondary outcomes include risk of fragility fracture by estimated glomerular filtration rate (eGFR) and Kidney Disease Improving Global Outcomes (KDIGO) risk categories. The cohort was a population of 2.72 million community-dwelling adults who had at least 1 measurement of creatinine and albuminuria over 11 years.

RF06 | PSAT155 Are We Following the Recommendations to Screen for and Treat the "Silent Killer" in Our Geriatric Population? A Quality Improvement Project

Abstract Introduction Osteoporosis is characterized by weakening of the bone, disruption of its architecture, and loss of skeletal strength, leading to increased risk of fragility fractures. According to the CDC, the prevalence of osteoporosis in 2017-2018 was 5.7% in males and 17.7% in adults aged 65 and older. Approximately 2 million osteoporosis fractures occur annually in the USA. The annual direct cost is estimated to be $25.3 billion by 2025. Implementing effective strategies to help with early diagnosis, treatment, and follow-up is fundamental. Our study aims to identify barriers that render the geriatric population with osteoporosis from receiving optimal medical care. Methods We retrospectively reviewed a sample of 119 patients of a GERIATRIC PACT Veteran administration (VA) clinic between 1/1/2018 and 8/30/2021 to identify patients diagnosed with osteoporosis and monitor the adequacy of education, treatment, and follow-up. Possible treatment barriers and subsequent consequences were noted. Results were presented using descriptive statistics. Results The mean age of the cohort was 83±7 years old, 90% (N=107) of them being males, with a mean BMI and Hb A1c of 27± 6 kg/m2 and 6. 0± 2.1%, respectively. From the total, we obtained a sample of 17.8% (N=15, 12M/3F) patients who had a previous diagnosis of osteoporosis without concurrent medical management. Eight patients (53%) didn't have Osteoporosis management or discussion of the treatment with the clinician at their initial geriatric appointment, and 5 patients didn't discuss osteoporosis in subsequent visits either. Poor mental or physical status, limiting patient follow-up or treatment, was identified in 40%(N=6) of the patients. Adverse reactions were seen in 6.6% (N=1). 20% of the patient were on drug holiday (N=3), and 20% (N=3) refused any osteoporosis treatment. 26.6%(N=4) of the patients had developed fragility fractures. From this subgroup, one patient refused the treatment, and 3 had no osteoporosis treatment discussion at their initial visit. Discussion Our results showed that a significant number of patients with osteoporosis had no screening or evaluation. Osteoporotic fractures were presented within a few months in 20% of them. No identifiable cost barriers or contraindications to osteoporosis treatment were noticed. Multiple factors could have contributed to these events. Lack of universal clinical reminder for osteoporosis screening per national VA guidelines fails to identify men at increased risk for osteoporosis and it does not address the lack of follow-up reminders on this topic. Public misinformation regarding osteoporosis treatment is another barrier that needs to be addressed with education. Plans to identify patients with no concurrent treatment are necessary. Conclusions In geriatric veterans, implementing tools to follow-up on patients with osteoporosis and identifying treatment barriers is an essential step for high-quality, integrated, and comprehensive patient care. Such tools need to be validated with future studies to ensure effectiveness. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:24 p.m. - 1:29 p.m.

ODP097 Hyperparathyroidism as a major risk factor of fracture and its prevalence in patients with hip fracture

Abstract Introduction Hyperparathyroidism is a risk factor of osteoporosis. Excess parathyroid hormone (PTH) accelerates bone loss via bone reabsorption and increases the risk of fragility fracture. Fragility fractures are associated with serious consequences in older patients. [1] This study aimed to look at the prevalence of hyperparathyroidism and vitamin D deficiency in geriatric patients (age &amp;gt;60) who presented with hip fractures in an Irish tertiary hospital. Methods Data was collected from Irish hip fracture Database (IHFD) and the Ortho-geriatric Electronic Patient Medical System (EPMS) between July 2019 and April 2020 (n=207). Demographic data and bone health profile (PTH, Vitamin D, and Calcium) were analysed using SPSS for statistical analysis. Results The median age of patients was 81 years (SD 8.7), and 68.3% of patients were female. Median 10-year probability of major osteoporotic and hip fracture risk is 22.5% and 12.2%, respectively. 29.9% was diagnosed with hyperparathyroidism with prevalence of primary and secondary hyperparathyroidism of 6.7% and 23.1%, respectively. The majority of these (87.3%) were normocalcaemic hyperparathyroidism. 50.7% were vitamin D deficient, with 11.5% being severely deficient (Vitamin D &amp;lt;20nmol/L). Conclusion The prevalence of hyperparathyroidism is higher in the hip fracture group than in the general population. [2] Vitamin D deficiency is also prevalent in this group. FRAX score indicated significant proportion of patients with high major osteoporosis and hip fracture risks. Routine bone health profile checks in this high-risk group allow early identification and management of hyperparathyroidism and vitamin D depletion, which can potentially reduce the risk of future fracture. Reference: 1. Bukata SV, DiGiovanni BF, Friedman SM, Hoyen H, Kates A, Kates SL, Mears SC, Mendelson DA, Serna Jr FH, Sieber FE, Tyler WK. A guide to improving the care of patients with fragility fractures. Geriatric Orthopaedic Surgery &amp; Rehabilitation. 2011 Jan;2(1): 5-37.2. Press DM, Siperstein AE, Berber E, Shin JJ, Metzger R, Jin J, Monteiro R, Mino J, Swagel W, Mitchell JC. The prevalence of undiagnosed and unrecognized primary hyperparathyroidism: a population-based analysis from the electronic medical record. Surgery. 2013 Dec 1;154(6): 1232-8 Presentation: No date and time listed

An Epidemiological Analysis of Orthopedic Fractures, a Retrospective Single-Center Study from Jordan

Background: Studies on musculoskeletal fractures are limited in Jordan. Therefore, this study includes all orthopedic fractures in the tertiary center from Jordan. Fractures are evaluated for etiologies, age distribution, gender, mechanism of injury, and associated injuries. Therefore, this could assist in discovering the needs of our healthcare system and endorse recommendations on fracture treatment and prevention. Materials and Methods: This retrospective study reviewed 3,387 fractures admitted from July 2018 to December 2021 at King Hussein Medical City in Amman, the capital of Jordan. Fractures were assessed regarding age, gender, mechanism of injury and variation across years. Fractures were allocated into eleven bones where forearm, hand, leg and foot were considered individual bones to facilitate analysis. Results: The males represented 57.8% of patients. The lower limb was affected in 47.4%, the femur was the most commonly affected bone (26.6%), and the proximal femur accounted for 20.9% of all fractures. Men were more likely to sustain injuries to long bone, hand and foot injuries, while women were at higher risk of fragility fractures. Most hospitalizations were in patients over the age of fifty. Two-thirds of injuries were induced by simple falls. Open fractures were reported in 7.3% of fractures and neurological and vascular injuries in 1.9% and 1.5%, respectively. Conclusions: Multicenter and epidemiological studies are needed to adequately assess orthopedic fractures in Jordan so that we can establish guidelines for fracture prevention and treatment.

Analysis of Bone Histomorphometry in Rat and Guinea Pig Animal Models Subject to Hypoxia.

Hypoxia may be associated with alterations in bone remodeling, but the published results are contradictory. The aim of this study was to characterize the bone morphometry changes subject to hypoxia for a better understanding of the bone response to hypoxia and its possible clinical consequences on the bone metabolism. This study analyzed the bone morphometry parameters by micro-computed tomography (μCT) in rat and guinea pig normobaric hypoxia models. Adult male and female Wistar rats were exposed to chronic hypoxia for 7 and 15 days. Additionally, adult male guinea pigs were exposed to chronic hypoxia for 15 days. The results showed that rats exposed to chronic constant and intermittent hypoxic conditions had a worse trabecular and cortical bone health than control rats (under a normoxic condition). Rats under chronic constant hypoxia were associated with a more deteriorated cortical tibia thickness, trabecular femur and tibia bone volume over the total volume (BV/TV), tibia trabecular number (Tb.N), and trabecular femur and tibia bone mineral density (BMD). In the case of chronic intermittent hypoxia, rats subjected to intermittent hypoxia had a lower cortical femur tissue mineral density (TMD), lower trabecular tibia BV/TV, and lower trabecular thickness (Tb.Th) of the tibia and lower tibia Tb.N. The results also showed that obese rats under a hypoxic condition had worse values for the femur and tibia BV/TV, tibia trabecular separation (Tb.Sp), femur and tibia Tb.N, and BMD for the femur and tibia than normoweight rats under a hypoxic condition. In conclusion, hypoxia and obesity may modify bone remodeling, and thus bone microarchitecture, and they might lead to reductions in the bone strength and therefore increase the risk of fragility fracture.

Quality of Life in osteoporotic patients.

Osteoporosis is responsible for fragility fractures, which are associated with impaired quality of life (QoL) and disability. The aim of the study was to evaluate the QoL in patients affected by osteoporosis and possible determinants. One-hundred thirty-four subjects followed at the osteoprosis outpatient clinic at our institution completed the QUALEFFO-41 questionnaire for quality of life. All subjects had undergone bone densitometry measurement and the FRAX index, summarizing the risk of fragility fracture, was calculated for each of them. The QoL in these subjects and its possible determinants were investigated with univariate and multiple linear regression analysis. Subjects with osteoporosis had lower scores in the domains of physical and social function of the QUALEFFO questionnaire in comparison with subjects with normal bome mineral density. Main factors associated with impairment in QoL were high FRAX score and body mass index (BMI). Physical and social function is reduced in osteoporotic subjects. High BMI and an increased risk of fragility fracture were main determinants of impairment in the QoL in this study.

Bone health in functional hypothalamic amenorrhea: What the endocrinologist needs to know.

In the original definition by Klinefelter, Albright and Griswold, the expression “hypothalamic hypoestrogenism” was used to describe functional hypothalamic amenorrhoea (FHA). Given the well-known effects of estrogens on bone, the physiopathology of skeletal fragility in this condition may appear self-explanatory. Actually, a growing body of evidence has clarified that estrogens are only part of the story. FHA occurs in eating disorders, overtraining, and during psychological or physical stress. Despite some specific characteristics which differentiate these conditions, relative energy deficiency is a common trigger that initiates the metabolic and endocrine derangements contributing to bone loss. Conversely, data on the impact of amenorrhoea on bone density or microarchitecture are controversial, and reduced bone mass is observed even in patients with preserved menstrual cycle. Consistently, oral estrogen-progestin combinations have not proven beneficial on bone density of amenorrheic women. Low bone density is a highly prevalent finding in these patients and entails an increased risk of stress or fragility fractures, and failure to achieve peak bone mass and target height in young girls. Pharmacological treatments have been studied, including androgens, insulin-like growth factor-1, bisphosphonates, denosumab, teriparatide, leptin, but none of them is currently approved for use in FHA. A timely screening for bone complications and a multidisciplinary, customized approach aiming to restore energy balance, ensure adequate protein, calcium and vitamin D intake, and reverse the detrimental metabolic-endocrine changes typical of this condition, should be the preferred approach until further studies are available.

Risk Factors Associated With Fragility Fracture Among Older Adults With Fragility Fracture: A Systematic Review

Aim: To investigate risk factors of fragility fractures among older people. Data Sources: The electronic databases employed were PubMed, Science Direct, and Google Scholar from 2016 to December 2021. Review Method: The methodological quality of the studies was assessed using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-sectional study. Two independent reviewers screened total 147 articles. Results: Twelve studies were finally included in this review that consisted of 7 cross sectional, 2 longitudinal and 3 cohort studies. Six studies were of good quality and six were fair. Studies that were of good quality showed that physical performance, muscle strength, and falls due to balance impairment were associated with an increased of fragility fractures. While the results for sarcopenia status were uncertain. Conclusion: This review suggests that physical functional related factors were main contributors to the risk of fragility fracture among older people. Lack of research in this area warrants more studies to be carried out in the future.

Definition, Assessment, and Management of Vitamin D Inadequacy: Suggestions, Recommendations, and Warnings from the Italian Society for Osteoporosis, Mineral Metabolism and Bone Diseases (SIOMMMS).

In the recent years, both the prescriptions of serum 25(OH)D levels assay, and vitamin D supplementation are constantly increasing, as well as the costs to be incurred relating to these specific aspects. As in many other countries, the risk of vitamin D deficiency is particularly high in Italy, as recently confirmed by cohort studies in the general population as well as in patients with metabolic bone disorder. Results confirmed the North-South gradient of vitamin D levels described among European countries, despite the wide use of supplements. Although vitamin D supplementation is also recommended by the Italian Medicine Agency for patients at risk for fragility fracture or for initiating osteoporotic medication, the therapeutic gap for osteoporosis in Italy is very high. There is a consistent proportion of osteoporotic patients not receiving specific therapy for osteoporosis following a fragility fracture, with a poor adherence to the recommendations provided by national guidelines and position paper documents. The failure or inadequate supplementation with vitamin D in patients on antiresorptive or anabolic treatment for osteoporosis is thought to further amplify the problem and exposes patients to a high risk of re-fracture and mortality. Therefore, it is important that attention to its possible clinical consequences must be given. Thus, in light of new evidence from the literature, the SIOMMMS board felt the need to revise and update, by a GRADE/PICO system approach, its previous original recommendations about the definition, prevention, and treatment of vitamin D deficiency in adults, released in 2011. Several key points have been here addressed, such as the definition of the vitamin D status: normality values and optimal values; who are the subjects considered at risk of hypovitaminosis D; opportunity or not of performing the biochemical assessment of serum 25(OH)D levels in general population and in subjects at risk of hypovitaminosis D; the need or not to evaluate baseline serum 25(OH)D in candidate subjects for pharmacological treatment for osteoporosis; how and whether to supplement vitamin D subjects with hypovitaminosis D or candidates for pharmacological treatment with bone active agents, and the general population; how and whether to supplement vitamin D in chronic kidney disease and/or chronic liver diseases or under treatment with drugs interfering with hepatic metabolism; and finally, if vitamin D may have toxic effects in the subject in need of supplementation.

Pharmacological, Nutritional, and Rehabilitative Interventions to Improve the Complex Management of Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease: A Narrative Review.

Osteoporosis is a highly prevalent condition affecting a growing number of patients affected by chronic obstructive pulmonary disease (COPD), with crucial implications for risk of fragility fractures, hospitalization, and mortality. Several risk factors have been identified to have a role in osteoporosis development in COPD patients, including corticosteroid therapy, systemic inflammation, smoke, physical activity levels, malnutrition, and sarcopenia. In this scenario, a personalized multitarget intervention focusing on the pathological mechanisms underpinning osteoporosis is mandatory to improve bone health in these frail patients. Specifically, physical exercise, nutritional approach, dietary supplements, and smoke cessation are the cornerstone of the lifestyle approach to osteoporosis in COPD patients, improving not only bone health but also physical performance and balance. On the other hand, pharmacological treatment should be considered for both the prevention and treatment of osteoporosis in patients at higher risk of fragility fractures. Despite these considerations, several barriers still affect the integration of a personalized approach to managing osteoporosis in COPD patients. However, digital innovation solutions and telemedicine might have a role in optimizing sustainable networking between hospital assistance and community settings to improve bone health and reduce sanitary costs of the long-term management of COPD patients with osteoporosis.